DOI: 10.1111/prd.

12415

REVIEW ARTICLE

Management and prevention of soft tissue complications in

implant dentistry

Daniel S. Thoma | Alfonso Gil | Christoph H. F. Hämmerle | Ronald E. Jung

Clinic of Reconstructive Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland

Correspondence
Daniel S. Thoma, Clinic of Reconstructive Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland.
Email: [email protected]

1 | I NTRO D U C TI O N 2 | A N ATO M Y O F TH E PE R I - ­I M PL A NT
M U COSA A N D S U S C E P TI B I LIT Y TO
Dental implants are frequently used to support fixed and removable I N FL A M M ATI O N
prostheses in partially and fully edentulous patients. Based on re-
cent systematic reviews including a plethora of clinical studies, high The anatomy of the peri-­implant mucosa differs from the gingiva
survival rates can be expected at both the implant and the restor- around natural teeth. First, the peri-­implant connective tissue fibers
ative level.1,2 run parallel to the implant surface and, in general, do not attach to
For a long time, implant research was focused on the peri-­ it, whereas the dento-­gingival fibers show a perpendicular disposi-
implant bone, establishing hard tissue quality and quantity as being tion, attaching directly to the root cementum. 21 Second, the vascular
the principal criteria for defining success.3 Therefore, adequate bone supply at implant sites is diminished because there is no periodontal
volume was a prerequisite prior to implant placement, with various ligament present and the only source of nourishment is derived from
ridge preservation and augmentation procedures performed accord- the supra-­periosteal blood vessels. 22 Third, the junctional epithe-
4
ingly. A facial bone thickness of at least 2 mm was suggested to lium around implants is more permeable and its connective tissue
maintain marginal bone levels around the implant over time.5 Crestal compartment shows fewer fibroblasts and a greater number of col-
bone loss6 and primary implant stability7 were considered as the crit- lagen fibers. 23 These anatomical differences render dental implants
ical factors for success, whereas the importance of the peri-­implant more susceptible to inflammation and subsequent bone loss from
soft tissues was frequently neglected. microbial challenge. 24 The maintenance of an adequate quantity
More recently, emerging evidence suggests that the peri-­implant and quality of mucosa surrounding the peri-­implant bone has been
soft tissues are key to maintaining peri-­implant health.8 Current long-­ demonstrated to be of paramount importance in maintaining peri-­
term clinical studies have shown stable and healthy peri-­implant soft implant health. 25
9 10
tissues after 7 and 12 years , even in the case of missing buccal Peri-­implant health is characterized by the absence of bleeding on
bone at implant sites. probing and stable marginal bone levels. Peri-­implant mucositis is de-
Various publications have evaluated the importance of soft tis- fined as the presence of bleeding on probing and/or suppuration but
11-­13
sues at dental implant sites from both a biologic and esthetic without any evidence of bone loss. Peri-­implantitis requires progres-
perspective.14,15 Accordingly, various indications16-­18 and treatment sive crestal bone level changes, in addition to bleeding on probing and/
options19,20 have been suggested. or suppuration, with or without deepening of peri-­implant pockets.26
The present narrative review focuses on the management, tim- The prevention of peri-­implant disease has become a major task
ing, specific interventions, and the prevention of soft tissue compli- in daily practice based on epidemiologic data suggesting that 30%
cations in implant dentistry. Besides the evidential background, this of all implants and 47% of all patients will experience peri-­implant
article provides a time line and a risk scale for different interventions mucositis, and that 10% of all implants and 20% of all patients will
to prevent and manage soft tissue complications. experience peri-­implantitis. 27

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. Periodontology 2000 published by John Wiley & Sons Ltd.

116 | 
wileyonlinelibrary.com/journal/prd Periodontology 2000. 2022;88:116–129.
THOMA et al. | 117

Indeed, there is increasing evidence demonstrating that the

long-­term maintenance of peri-­implant health is a difficult challenge
Management of lack of attached mucosa:
and that trans-­mucosal healing and adequate management of the
(A) before implant placement: highly recommended.
peri-­implant mucosa may be a decisive factor in avoiding the de-
(B) with implant placement: less recommended.
velopment of complications. In addition, a recent systematic review
(C) within the implant-­healing phase: less recommended.
recommended soft tissue augmentation procedures to maintain
(D) with abutment connection: recommended.
and improve peri-­implant health at dental implants, suggesting that
(E) after delivery of the implant reconstruction: less
these procedures limit marginal bone loss and reduce the incidence
28 recommended.
of bleeding on probing over the long term.

3 | S O F T TI S S U E CO M PLI C ATI O N S consensus report from the Consensus Conference of the European
A RO U N D I M PL A NT S Association for Osseointegration39 stated that “there is a lack
of high-­quality studies evaluating the need for attached mucosa
Three types of soft tissue complications may develop around dental around implants to maintain health and tissue stability.” By contrast,
implants and represent an everyday clinical challenge, namely, a lack recent systematic reviews demonstrated that a deficient band of
of attached mucosa, volume deficiency, and peri-­implant mucosal attached tissue around implants is associated with greater plaque
recession. accumulation, mucosal inflammation (assessed by bleeding on prob-
After tooth extraction, a significant reduction in the ridge dimen- ing), development of soft tissue recession, and patient discomfort
sions occurs. 29-­31 This shrinkage of the alveolar ridge is not limited to while performing oral hygiene.11,13,40 This is further underlined by
the bone but may also be accompanied by a loss of attached tissue a recent systematic review indicating that soft tissue grafting pro-
32
and/or a soft tissue volume deficiency. cedures to gain attached mucosa resulted in a significantly greater
The incidence of a complete absence of an adequate band of at- improvement in gingival index values compared with maintenance
tached and keratinized tissue has been reported to range from 46% groups (with or without attached tissue) and, for final marginal bone
to 74% of all inserted implants.33 By contrast, incidence data for the levels, statistically significant differences were calculated in favor of
lack of mucosal volume around implants has not been reported in the an apically positioned flap plus autogenous grafts vs all control treat-
literature because of the difficulties in assessing it in a noninvasive ments (apically positioned flap alone, apically positioned flap plus a
manner. Data, however, suggests that it is a common finding among collagen matrix, maintenance without intervention [with or without
implants placed in the esthetic zone and its occurrence plays a role residual attached tissue]). 28
in the mucosal color match of implants compared with their adjacent
dentition. The color of the peri-­implant tissues matches those of the
neighboring teeth in only 33% of cases.34 This mismatch is more obvi- 3.2 | Soft tissue volume
ous in thinner biotypes, where a discoloration may still be clinically no-
ticeable.35 This, to some extent, underlines the necessity to perform Soft tissue volume refers to the vertical and horizontal thickness of
soft tissue grafting procedures, predominantly in the esthetic zone. the peri-­implant tissues and is important for the formation of a bio-
The occurrence of recession defects on the buccal side of dental logic width around implants. Peri-­implant bone undergoes a remod-
implants is influenced by various factors, such as tissue phenotype, eling process to allow sufficient space for the peri-­implant soft tissue
facial bone level, implant angulation and axis, interproximal marginal to be formed.41,42 The assessment of soft tissue volume is challenging
bone level, implant design, and the level of first bone to implant con- because of the scarcity of measuring tools able to evaluate soft tis-
tact.36 The incidence of such recession defects varies, depending sue changes. The introduction of digital optical scanning/analysis as an
on the time point when dental implants were placed. For immedi- assessment method has allowed measurement of changes in soft tis-
ate implants, an advanced recession at 10% of implants has been sue volume over time.43 Indications for mucosal volume augmentation
37
reported, whereas for delayed implants, > 1 mm of midfacial soft include esthetic improvements, prevention of recession, facilitation
tissue recession can be expected in 60% of implants.38 of oral hygiene, and maintenance of marginal bone and peri-­implant
All three types of soft tissue complication are, therefore, a com- health.
mon clinical finding and may hamper peri-­implant health and the es- Horizontal tissue thickness (measured on the buccal side of the
thetic outcome of implant-­borne reconstructions. implant) has been associated with buccal tissue stability,8,44 less mar-
ginal bone loss,45 and improved esthetic outcomes.35 Moreover, a suf-
ficient vertical thickness of the mucosal tissues (measured coronal to
3.1 | Attached mucosa the implant) has been associated with decreased marginal bone loss
compared with thinner biotypes.46,47 As shown in a recent systematic
The influence of a sufficient width of attached tissue around den- review,28 soft tissue grafting procedures for gain of mucosal thickness
tal implants still remains controversial in the dental literature. A resulted in significantly less marginal bone loss over time.
118 | THOMA et al.

3.3 | Buccal soft tissue recession graded recommendations (highly recommended, recommended, or
less recommended) will be given within text boxes for the time point
Peri-­implant soft tissue recession can be a major esthetic complica- of the treatment, depending on the indication and based on existing
tion, predominantly when occurring in the anterior maxilla. A num- and, to some extent, limited evidence.
ber of factors appear to influence the level of the marginal mucosa.36
Those that have been shown to have a greater negative impact on
the stability of the peri-­implant mucosa when they are not present 4.1 | Attached and keratinized mucosa
are the quality of the mucosa (the presence of attached mucosa),
the attachment levels of the adjacent teeth, and the thickness of the Where there is a lack of attached mucosa, the preferred method of
28,48
mucosa. treatment is an apically positioned flap/vestibuloplasty procedure
From an esthetic point of view, the gray color of the titanium with or without the combination of a graft material.19 The use of au-
implant and the implant components may create a major problem togenous transplants (free gingival graft or subepithelial connective
when they are exposed and visible as a result of peri-­implant mu- tissue graft) is considered to be the gold standard, with a reported
49-­51
cosal recession. Unlike natural teeth, recession around implants increase in attached mucosa ranging from 1.4 to 3.3 mm. Other ther-
with a minimal amount of titanium exposure can dramatically impact apeutic treatment modalities include the apically positioned flap/
esthetic appearance,52 thus being unacceptable to the patient and vestibuloplasty in conjunction with allogenic dermal matrix grafts or
requiring additional surgical and/or restorative treatment. a collagen matrix. These options reduce treatment time and patient
In addition, recession defects have also been associated with a morbidity but are less well investigated.19 The therapeutic approach
12
deficient band of attached mucosa around the implant, and sub- to increase the width of attached mucosa can be more predictably
sequently, a greater difficulty for patients to properly perform oral performed prior to implant placement (time point A). Augmentation
hygiene. When implant surfaces become exposed, especially for im- of attached tissue dimensions to improve the quality of soft tissues
53
plants with a rougher surface, plaque accumulation will occur, thus does simplify the subsequent therapeutic steps, such as bone aug-
potentially initiating the development of peri-­implant disease. mentation surgery or the insertion of a dental implant, thereby re-
ducing the risk of tissue dehiscences with subsequent membrane/
graft exposure. Based on a systematic review, it was recommended
4 | M A N AG E M E NT A N D PR E V E NTI O N O F to address a lack of attached tissue at second stage surgery (time
S O F T TI S S U E CO M PLI C ATI O N S point D), where an apically positioned flap/vestibuloplasty in com-
bination with a free gingival graft or a collagen matrix appeared to
The management and prevention of soft tissue complications are provide predictable outcomes. 20
vital to prevent adverse outcomes in implant dentistry.
The selection of the type and time point of treatment depends
upon the clinical characteristics of each case and the patient's wishes 4.2 | Soft tissue volume
and needs. A thorough review of the patient's medical history, peri-
odontal status, bone quality and quantity, and restorative needs Soft tissue grafting procedures to increase mucosal thickness are
should be performed prior to any soft tissue-­management procedure. successfully employed to eliminate soft tissue volume deficiencies
The proposed clinical decision tree is based on five time points around dental implants. For immediate implants, strong evidence
during implant therapy: suggests that implant placement and simultaneous hard tissue
grafting should be combined with a soft tissue graft to counteract
(A) prior to implant placement (with or without tooth extraction). contour and remodeling processes following the surgical interven-
(B) simultaneous with implant placement. tion. The addition of a subepithelial connective tissue graft demon-
(C) within the implant-­healing phase (between implant placement strated improved esthetics, as assessed by the pink esthetic score
and abutment connection). and less midfacial recession of the peri-­implant soft tissues. 55-­57
(D) simultaneous with abutment connection. Dental implants may be placed early, delayed, or late. At these
(E) after delivery of the implant reconstruction. time points, remodeling processes may have already led to volume
deficiencies. As such, following implant placement with or without
This timing of treatment has not been thoroughly researched in concomitant guided bone regeneration, soft tissue volume grafting
the literature, but may exert a clinical impact on the final result of the can be performed during second stage surgery. The combination of
implant reconstruction. Management of soft tissue conditions prior abutment connection and soft tissue grafting reduces the need for
to delivery of the reconstruction (A, B, C, and D) can be considered further surgical intervention. The previously mentioned systematic
as primary prevention of complications and may aid the clinician in review20 determined that the use of an apically positioned flap in
achieving peri-­implant tissue stability. Once the restoration has been combination with a subepithelial connective tissue graft appeared to
delivered (E), the treatment of these complications is more compli- be a reliable treatment option to increase soft tissue volume during
cated and the predictability is reduced. 54 Throughout this review, second stage surgery.
THOMA et al. | 119

For delayed implants, a case series calculated that guided bone Only a few prospective studies have evaluated mucogingival sur-
regeneration was responsible for 57%, and soft tissue grafting for gical procedures to correct mucosal recessions.16,54,59 The results,
58
43%, of the total final volume. This indicates the importance of soft based on the use of coronally advanced flaps in combination with
tissue grafting to enhance the final esthetic outcome. Autogenous a subepithelial connective tissue graft in all three studies, showed
tissue (subepithelial connective tissue graft) is considered the treat- coverage of the recession ranging from 66% to 96%. The implants
ment of choice for soft volume augmentation around dental im- studied were treated when they were single healthy implants. In a
plants, resulting in an increase in soft tissue thickness in partially systematic review,60 it was concluded that mucosal recessions can
edentulous sites. Free gingival grafts have also been employed but be treated with an expected gain of 1.6 mm in vertical soft tissue
with limited results and decreased color matching.19 More recently, height, but without any long-­term evidence of the stability of the
soft tissue substitutes have been applied, serving as an alternative tissues. However, midfacial peri-­implant soft tissue recession cover-
to a subepithelial connective tissue graft. Based on a randomized age is less successful than recession coverage around natural teeth,
controlled clinical trial, employing either a subepithelial connective with Miller recession class I and II being very predictably treated and
tissue graft or a newly developed collagen matrix, both treatment maintained.61
options resulted in an increase in soft tissue volume of up to 1.8 Certain factors should be evaluated before treatment, such as
mm. However, the use of a newly developed collagen matrix reduced the presence of buccal bone, the attachment of the adjacent teeth,
patient morbidity.18 the implant position, the emergence profile of the reconstruction,
and the tissue biotype. Treatment is indicated for single healthy im-
plants within their bony housing, where the implant position is cor-
rect and where adjacent teeth have a well-­maintained periodontium.
There are cases when such surgery is indicated. Overcontoured
Management of lack of soft tissue volume:
restorations with emergence profiles impinging on the soft tissue
(A) before implant placement: recommended.
should be changed to provide space for the tissue to develop. When
(B) with implant placement: highly recommended for im-
the implant is placed in an exaggerated buccal position outside the
mediate implants; less recommended for other time
bony housing and a buccal dehiscence occurs, the only possible
points.
treatment is removal of the implant.
(C) within the implant-­healing phase: highly recommended.
(D) with abutment connection: recommended.
(E) after delivery of the implant reconstruction: less
recommended. Management of soft tissue recession:
(A) before implant placement: not possible.
(B) with implant placement: not possible.
Later time points for volume or attached mucosa augmentation, (C) within the implant-­healing phase: not possible.
especially after the insertion of the definitive reconstruction, are usu- (D) with abutment connection: recommended.
ally not included as part of the regular treatment, and are used instead (E) after delivery of the implant reconstruction: recommended.
to compensate for loss of quantity and/or quality of tissue occurring
over time.59 These rescue treatments usually offer a decreased pre-
dictability and require more technique-­sensitive surgical skills.54 5 | C LI N I C A L CO N C E P T S FO R
M A N AG E M E NT A N D PR E V E NTI O N O F
S O F T TI S S U E CO M PLI C ATI O N S A RO U N D
4.3 | Buccal soft tissue recession I M PL A NT S

The midfacial mucosal level around a dental implant may be influ- The clinical concepts as presented in the current review is based on
enced by a wide range of clinical factors.36 Depending on the se- a risk assessment of the peri-­implant tissues encompassing different
verity of the buccal mucosal dehiscence, treatment approaches time points for the prevention and management of soft tissue com-
include mucogingival surgery, the replacement of the crown, or even plications around implants. Depending on the stage of treatment,
removal of the implant. Once the implant restoration is in place and different approaches can be performed, with differing levels of suc-
recession occurs, management poses a greater challenge for the cli- cess and predictability (Figure 1).
nician. Even although there is no direct cause-­and-­effect evidence, Bearing in mind that the concept presented lacks scientific ev-
there is a clinical understanding that the amount of coverage of the idence, the predictability of surgical and prosthetic treatment ap-
soft tissue augmentation surgery will be governed by interproximal pears to be higher if performed during earlier stages of implant
attachment of the adjacent teeth, the presence of bone on the buc- therapy. That said, managing complications after delivery of the de-
cal surface of the implant, the horizontal and vertical implant posi- finitive reconstructions is considered to be the least predictable. It
tions, and the thickness of the peri-­implant mucosa. is also suggested that the number of procedures (eg, hard and soft
120 | THOMA et al.

F I G U R E 1 Risk scale of soft tissue

management before, during, and after
implant placement. AM, attached mucosa;
Aug, augmentation

A B C D E

F G H I J

K L M N

F I G U R E 2 Clinical case of soft tissue management simultaneous to ridge preservation and in combination with implant placement. A,
Patient's initial situation. B, Periapical radiograph of tooth 21. C, Alveolar ridge preservation. D, Palatal sub-­epithelial connective tissue
graft. E, Sealing of the socket in ridge preservation. F, Post-­operative healing after 6 months. G, Cone-­beam computed tomography scan of
healed site 21. H, Implant placement. I, Soft tissue grafting with volume-­stable xenogeneic collagen matrix. J, Post-­operative healing after 2
weeks. K, Abutment connection with U-­Flap. L, Emergence profile of implant 21. M, Periapical radiograph of osseointegrated implant 21. N,
Patient's final situation after receiving the implant supported-­restoration

tissue grafting) per time point is limited to increase the predictability A 32-­year-­old patient (Figure 2) presented with root resorption
of soft tissue management. at a central incisor (tooth 21) (A,B) following trauma 10 years pre-
viously. The tooth was extracted and ridge preservation was per-
formed with the use of a xenograft (C) and autogenous connective
5.1 | Clinical concept for prevention of soft tissue tissue from the palate (D,E). The grafted area healed uneventfully
complications before implant placement (F), and the edentulous area showed sufficient tissue height, no in-
vagination, but a slight volume deficiency on the buccal aspect at
Treatment planning encompassing dental implants should include a 6 months. A cone beam computed tomography scan showed suf-
risk assessment of the soft tissue situation prior to implant surgery. If ficient bone to place a dental implant, without the need for further
there is any type of soft tissue deficiency (such as a lack of attached bone augmentation (G). An implant was placed (H) and a volume-­
mucosa and/or lack of volume), this should be addressed before any stable xenogeneic collagen matrix (Fibro-­Gide, Geistlich Pharma AG,
surgery is undertaken at the level of the bone. Once the condition Wolhusen, Switzerland) was placed on the crestal and buccal side of
of the edentulous mucosa is ideal, implant-­related surgery can be the implant to increase the tissue thickness and to compensate for
performed with increasing predictability. the missing tissue volume (I). The situation after 2 weeks of healing
THOMA et al. | 121

demonstrated increased height and bucco-­oral width of the soft sufficient soft mucosal thickness and attached mucosa and even
tissue (J). A U-­flap was performed during abutment connection to partial root coverage (K) was obtained once the definitive crown was
mobilize the tissue to the buccal side (K). An adequate emergence delivered 4 months later. The situation remained biologically stable
profile with increased horizontal thickness was created through the and esthetically pleasing at the 7-­year follow-­up (L).
use of a provisional restoration (L). The definitive reconstruction was A 46-­year-­old patient presented with a missing tooth 11 (Figure 4)
a screw-­retained ceramic reconstruction. The situation postdelivery and severe attachment loss at the mesial aspect of the neighboring
shows stable bone levels (M) and stable soft tissue conditions (N). tooth 12 (A). The soft tissue deficit was severe, in both the horizon-
A 36-­year-­old patient (Figure 3) presented with a missing tooth tal and vertical dimensions in the edentulous area. Moreover, deep
21 with deficient soft tissues in the edentulous area 21 and at the interproximal recession as a result of the loss of attachment was pres-
adjacent tooth 22 (A,B). There was a lack of volume, a lack of at- ent at the adjacent lateral incisor 12 (B). The priority in this case was
tached and keratinized tissue, deep soft tissue invaginations, and to improve the soft tissue condition until a stable situation could be
severe attachment loss at the neighboring tooth 22. Prior to any sur- achieved. Accordingly, orthodontic extrusion was performed on tooth
gical intervention at the level of the bone, a preimplant soft tissue 12 to regain the missing mesial attachment. After 6 months of extru-
grafting procedure was considered mandatory. Therefore, the eden- sion (C), the interproximal tissue had advanced coronally and there
tulous area was grafted with subepithelial connective tissue from was substantial clinical attachment level gain. Tooth 12 was then ex-
the palate (D) using a combination of a limited flap with a tunneling tracted (D) and a subepithelial connective tissue graft was harvested
technique (C). Following graft stabilization, the tissue was coronally from the palate and stabilized in the recipient site (E). The healing after
positioned with sutures (E) and a resin-­bonded provisional crown 6 weeks demonstrated a significantly increased mucosal thickness
was delivered. Healing after 8 weeks demonstrated an increase in (F). Subsequently, bone augmentation was performed by means of
volume with an improved soft tissue situation (F). An implant was an autogenous block graft harvested from the mandibular symphy-
then placed with a simultaneous guided bone regeneration approach sis. The block was stabilized with two screws (G) and left to heal for
(G) with the use of a xenograft and a nonresorbable membrane. The 4 months. The healing was uneventful and the 4-­month follow-­up sit-
sutures were removed 10 days later. At this time point, the tissues uation showed a ridge with increased volume (hard and soft tissue) (H).
had healed in a more coronal position (H). The implant was left to A dental implant was placed in position 11 with simultaneous guided
heal submerged for 6 months. After healing, abutment connection bone regeneration using a xenograft and a resorbable collagen mem-
was performed with a U-­flap (I) that further increased the soft tissue brane (I). After 3 months of submerged healing (J), abutment connec-
volume on the buccal side (J). An adequate emergence profile with tion was performed and the emergence profile was created by use of

A B C D

E F G H

I J K L

F I G U R E 3 Clinical case of soft tissue management prior to implant and guided bone regeneration surgery. A-­B, Patient's initial situation.
C, Minimally-­invasive flap combined with tunneling technique. D,Palatal sub-­epithelial connective tissue graft. E, Suturing with resin bonded
provisional. F, Post-­operative healing after 8 weeks. G, Guided bone regeneration simultaneous to implant placement. H, Flap closure with
sutures. I, Abutment connection with minimal U-­Flap. J, Abutment connection with healing abutment. K, Emergence profile of the implant. L,
Seven year follow-­up
122 | THOMA et al.

A B C D

E F G H

I J K L

F I G U R E 4 Clinical case of soft tissue management prior to tooth extraction and prior to block bone graft and posterior implant
placement. A-­B, Patient's initial situation. C, Orthodontic extrusion on tooth 12 after 6 months. D, Extraction of tooth 12. E, Palatal
subepithelial connective tissue graft stabilization. F, Post-­operative healing after 6 weeks. G, Bone augmentation with an autogenous block
bone graft. H, Post-­operative healing after 4 months. I, Implant placement 11. J, Post-­operative healing after 3 months. K, Implant-­supported
restoration 11 with a distal cantilever 12. L, Clinical situation after y ears of delivery of the restoration

A B C D

E F G H

I J K L

F I G U R E 5 Clinical case of soft tissue management simultaneous to implant placement and guided bone regeneration. A-­B, Patient's
initial situation. C, Immediate implant placement after extraction of tooth 11. D, Guided bone regeneration performed buccal to implant 11.
E, Collagen membrane adapted to seal the socket. F, Sub-­epithelial connective tissue graft. G, Partial thickness pouch buccal to the implant
with autogenous graft. H, Post-­operative healing after 3 months. I, Implant-­supported provisional restoration. J, Conventional open tray
impression of implant 11. K-­L , Implant-­supported restoration on 11 after one year follow-­up
THOMA et al. | 123

a provisional reconstruction. The implant reconstruction (position 11) A 22-­year-­old patient presented with a missing tooth 21 (Figure 6)
was screw-­retained with a distal cantilever for site 12 (K). Clinical pic- as a result of a failed root canal treatment (A). An implant was placed
tures 4 years after the delivery of the reconstruction demonstrated without any augmentation procedure (B). The healing after 1 month
healthy and stable tissue and a pleasing esthetic outcome (L). showed a deficiency in buccal tissue volume (C). A soft tissue aug-
mentation was performed using a connective tissue graft harvested
from the palate and by the use of a partial thickness flap (D). The graft
5.2 | Clinical concept for prevention of soft tissue was stabilized with sutures on the palatal side and positioned coro-
complications with implant placement nally and buccally. The flap was then sutured with a tension-­free mat-
tress suture and single interrupted sutures (E). Healing after 2 months
There are situations when the soft tissue condition is inadequate in was uneventful and showed increased thickness in both the horizon-
volume following tooth extraction but without being sufficiently de- tal (F) and vertical dimensions (G). At the point of delivery of the re-
ficient to contraindicate implant placement. In this situation, the soft construction, sufficient buccal tissue volume had been created and
tissue augmentation surgery can be performed at the same time as formed an emergence profile mimicking the one of the contralateral
implant placement, provided that the graft can be stabilized over the tooth site (H). The follow-­up situation after 3 years showed a stable
implant and no additional guided bone regeneration is needed. If the peri-­implant mucosa with a natural and esthetically pleasing result (I).
implant site is lacking attached tissue, the soft tissue augmentation
surgery should be performed prior to implant placement or during
the implant-­healing period, but not simultaneously because of the 5.4 | Clinical concept for prevention of soft tissue
difficulty in stabilizing the graft. complications during abutment connection
A 65-­year-­old patient presented (Figure 5) with a fractured
central incisor (tooth 11) (A,B). After analyzing the bone dimen- Soft tissue grafting procedures are commonly performed in conjunc-
sions (sufficient palatal bone) and the favorable soft tissue con- tion with abutment connection. Because of the need for a surgical
dition (adequate interproximal attachment levels), an immediate intervention (abutment connection), surgical procedures to gain at-
implant was planned simultaneously with the extraction. The tached mucosa as well as to provide mucosal thickness can be ad-
tooth was extracted with caution to preserve the buccal plate. dressed at the same time point. Whereas in the esthetic zone a lack
A bone-­level implant was placed into the palatal cortical bone, in of volume is often observed, in the nonesthetic area surgical proce-
a screw-­retained position (C). The gap between the implant and dures usually address a lack of attached mucosa.
the buccal bone was grafted with a particulate xenograft (D) and A 55-­
year-­
old patient presented with partial edentulism
a resorbable collagen membrane was adapted and used to cover (Figure 7). She had undergone multiple extractions; one implant had
the exposed bone graft (E). An autogenous connective tissue graft been placed (site 24) and subjected to submerged healing in the max-
was harvested from the tuberosity (F) and was placed in a previ- illary left posterior quadrant (A). During abutment connection, a de-
ously created partial thickness pouch, buccal to the implant (G). A ficient soft tissue condition (with a shift of the mucogingival junction
healing abutment was placed and the implant was left to heal for towards the palate) was observed. A partial thickness incision was
a period of 4 months. The healing after 3 months demonstrated raised distal to the abutment tooth (B). The flap was then sutured
a favorable tissue thickness on the buccal side (H). The patient apically and secured with periosteal sutures (C). The implant cover
was provided with a provisional restoration to wear for another screw was removed and the healing abutment placed (D). A free gin-
3 months to shape the emergence profile of the implant (I). Once gival graft was harvested from the palate (E). The graft was trimmed
the desired shape of the mucosa was achieved, an open tray im- to fit the recipient site (F) and was then secured with sutures to the
pression was performed (J) to fabricate the definitive reconstruc- palatal side of the flap (G). The additional use of overlapping cross
tion. The final situation 1-­year postdelivery of the porcelain fused sutures stabilized the graft on the wound bed (H). After 4 weeks of
to metal reconstruction is illustrated from both a buccal (K) and healing, the recipient site was well integrated and showed a signifi-
occlusal perspective (L). cant increase in the width of attached mucosa (I). After 2 years, the
grafted site still demonstrated sufficient width of attached tissue
with no signs of scar formation (J).
5.3 | Clinical concept for prevention of soft tissue
complications within the implant-­healing phase
5.5 | Clinical concept for management of soft
During the implant-­
healing period, the soft tissue condition can tissue complications following delivery of the
be easily assessed for any lack of volume or lack of attached tis- reconstruction
sue. Performing the soft tissue augmentation on its own allows for
an undisturbed healing phase following implant placement, with or Once the implant reconstruction is delivered, any soft tissue defi-
without bone augmentation. Therefore, the use of partial thickness ciencies (considered a complication) will be less predictable to treat.
flaps allows for stabilization of the soft tissue grafts without affect- The management of such complications is still possible in some
ing the implant or the bone healing. cases. Usually, the most noticeable type of soft tissue complication
124 | THOMA et al.

A B C

D E F

G H I

F I G U R E 6 Clinical case of soft tissue management within the implant healing phase, after implant placement and before abutment
connection. A, Patient's initial situation with missing tooth 21. B, Implant placement without augmentation on 21. C, Post-­operative healing
after one month. D, Placement of a sub-­epithelial connective tissue graft buccal and occlusal to the implant. E, Primary wound closure with
sutures. F-­G , Post-­operative healing after 2 months. H, Implant-­supported restoration on 21. I, Clinical situation at three year follow-­up

following implant crown delivery is the development of a recession thickness in the buccal area had to be addressed through soft tissue
on the buccal side of the implant. This can have a very negative im- augmentation surgery. A tunnel was created through the sulcus of
pact on the esthetic appearance of the reconstruction and may be the adjacent teeth (G). A thick connective tissue graft from the pal-
considered a failure by the patient. The treatment of such buccal ate was harvested (H). Anchorage sutures were placed through the
mucosal dehiscences depends on multiple factors including the im- sulcus (I) and the graft was then introduced through the tunnel and
plant position and depth, the tissue phenotype, and the periodon- stabilized with sutures (J). The situation after placement of the su-
tal attachment of the adjacent teeth. When the implant is correctly tures (K) shows a coronal advancement of the tunnel with the graft
positioned, and the periodontal attachment of the adjacent teeth is in place on the buccal side. After 2 years, the implant recession cov-
preserved, soft tissue augmentation surgery can be performed to erage remained stable with increased thickness of the peri-­implant
improve the situation. Other treatment options include changing the tissues (L).
reconstruction, or even removal of the implant. A 38-­year-­old patient was (Figure 9) very dissatisfied with the
A 46-­year-­old patient presented (Figure 8) with an esthetic con- esthetic result of an implant-­supported restoration on 11 position
cern attributable to the gray appearance of the implant caused by (A). After removing the reconstruction (B), various soft tissue pre-
a buccal dehiscence of the peri-­implant soft tissues (A). This dehis- dictive factors were analyzed, such as the position of the implant,
cence had developed following delivery of the final implant-­borne the thickness of the mucosa, and the level of attachment of the
reconstruction. An occlusal view of the situation shows a lack of neighboring teeth (C). Because of the excessive buccal position of
soft tissue volume buccal to the implant (B). Initially, the crown was the implant, it was decided that soft tissue augmentation surgery
removed (C,D) and the implant abutment was reduced in thickness was not indicated and the tissue was left to heal without the implant-­
and polished to allow for better soft tissue adaptation (E). The recon- retained crown in place. Following an initial healing period, the mu-
struction was also modified to cover the metal part of the abutment cosa was positioned at a more coronal level (D). Nevertheless, there
and to improve the situation (F). Nevertheless, the lack of tissue was still a significant lack of volume from the horizontal aspect in
THOMA et al. | 125

A B C D

E F G H

I J

F I G U R E 7 Clinical case of soft tissue management at abutment connection. A, Patient's initial situation. B, Partial thickness incision
buccal to placed implant 24. C, Apical suturing of the flap. D, Healing abutment placed on implant 24. E, Free gingival graft from the palate. F,
Trimming of the free gingival graft. G-­H, Stabilization of the free gingival graft with sutures. I, Post-­operative healing after 4 weeks. J, Clinical
situation after 2 years of follow-­up

site 11 (E). A connective tissue graft was harvested and secured 6 | DISCUSSION
with sutures on the crestal and buccal side of the implant and left
to heal submerged (F,G). A resin-­bonded bridge was then fabricated The prevention and management of soft tissue complications is of
and utilized as the means of reconstruction (H). The esthetic result key importance in modern implant dentistry. Therefore, assessment
was significantly improved with no graft surgery. The outcome re- of soft tissue conditions from a quantitative and qualitative perspec-
mains stable after 3 years (I). tive should be part of the overall treatment plan. Such an assessment
126 | THOMA et al.

A B C D

E F G H

I J K L

F I G U R E 8 Clinical case of soft tissue management after the delivery of the implant reconstruction. A, Patient's initial situation with
implant recession on 21. B, Patient's initial situation with reduced buccal volume. C-­D, Implant restoration removed. E, Implant abutment
polished. F, Modification of implant-­supported restoration 21. G, Tunneling procedure around implant mucosa and adjacent teeth. H, Palatal
sub-­epithelial connective tissue graft. I, Placement of anchorage sutures. J, Stabilization of graft inside the tunnel with anchorage sutures. K,
Coronal advancement of the tunnel with sutures. L, Clinical situation after 2 years follow-­up

will dictate whether soft tissue management is needed and, if in- potential development of peri-­implantitis.
dicated, when the ideal time point would be to perform such a
procedure. This approach helps clinicians to prevent soft tissue com- Recent evidence has shown the importance of a healthy peri-­
plications that can jeopardize both biologic and esthetic outcomes. implant mucosa, both from a biologic19 and an esthetic perspec-
Cases with peri-­implant soft tissue complications generally in- tive.16 According to a current systematic review, 28 soft tissue
volve: (a) a lack of attached and keratinized tissue; (b) insufficient grafting procedures can be recommended for gain of attached tis-
volume; (c) development of mucosal dehiscences; or (d) a combina- sue and increase of mucosal thickness. For the former, the use of
tion of (a), (b), and (c): an apically positioned flap in conjunction with autogenous grafts
results in greater improvement compared with sites without a sur-
• A lack of attached mucosa has been associated with greater gical intervention. For the latter, the use of autogenous grafts is
plaque accumulation, greater mucosal inflammation, higher generally recommended and results in more stable marginal bone
chances of developing soft tissue recession defects, and difficul- levels.
11,13,17,40
ties in performing proper maintenance for the patient. Apart from the importance of the different grafting techniques,
• A lack of soft tissue volume can have a crucial impact on the final the timing of these particular interventions is important and has an
results of the implant reconstruction. Mucosal thickness has impact on the overall risk of the therapy. Consideration should be
a significant influence on color changes of the mucosa35,62 and given to the quantity and quality of both the attached mucosa and
34
plays a crucial role in soft tissue esthetics. Moreover, thin soft the mucosal thickness present. It is generally understood in cases of
tissues have been demonstrated to have a negative effect on a lack of attached tissue or mucosal volume that an earlier surgical
marginal bone levels28,47 and present a greater risk of developing intervention results in greater predictability.
recession.44 Concept-­wise, the ideal time point to manage deficient soft tis-
• The development of a peri-­implant buccal soft tissue recession sue defects is considered to be prior to implant placement. Several
defect can expose the gray color of the abutment or of the implant authors have described techniques to address the soft tissues at
and cause an esthetic complication to the reconstruction.16,52,54 the time of tooth extraction63-­65 and various techniques have been
Unlike teeth, where minimal recession does not always result in an described; among these are the use of a free gingival graft or a
esthetic concern, patients do not accept the persistence of even connective tissue graft harvested from the palate to optimize the
minimal recession at the implant site following therapy.59 In addi- soft tissues in the short term. This time point of management al-
tion, the exposure of the implant creates a favorable environment lows for an improvement in soft tissue condition (the presence of
for plaque accumulation and biofilm formation, which may lead to a wide band of attached tissue and a thick mucosa horizontally and
THOMA et al. | 127

A B C

D E F

G H I

F I G U R E 9 Clinical case of soft tissue management after the delivery of the implant reconstruction. A, Patient's initial situation with soft
tissue margin discrepancy. B-­C , Removal of the implant-­supported restoration 11. D, Healing after 4 weeks without the restoration 11. E,
Soft tissue volume deficiency on site 11. F, Stabilization of a sub-­epithelial connective tissue graft buccal and occlusal to the implant. G,
Primary wound closure with sutures. H, A resin bonded bridge cemented on tooth 11. I, Clinical situation after 3 year follow-­up

vertically) before any surgery is performed at the level of the bone. an apically positioned flap/vestibuloplasty in the maxilla, and an
High predictability and reliability for a pleasing esthetic result can be apically positioned flap/vestibuloplasty in combination with a free
expected for future type 2 or type 3 implant placement. gingival graft or xenogeneic graft material in the mandible, both ap-
The second most optimal time point for soft tissue management is peared to provide favorable outcomes. To increase the soft tissue
during the healing phase after implant placement. Following implant volume, a roll envelope flap in the maxilla or an apically positioned
installation, clinicians usually wait for 2-­4 months before loading flap plus a connective tissue graft in the mandible appear to be the
the implant. If it is perceived that the peri-­implant mucosa is defi- most predictable treatment options.
cient, soft tissue grafting procedures can be performed as a single The simultaneous approach (immediate implant or combining
intervention, thereby not hampering the healing of the augmented abutment connection in conjunction with soft tissue grafting) re-
bone beneath or the soft tissue graft itself. Keeping the implant sub- duces the morbidity of the treatment by sparing the patient addi-
merged during healing enables proper positioning and stabilization tional surgery. Limitations apply if the implant or the abutment could
with sutures of the graft buccal and/or crestal to the implant. interfere with the stabilization and proper positioning of the soft
The third most optimal time point is simultaneous with implant tissue graft. The predictability of the soft tissue augmentation pro-
placement or at the time of abutment connection. Recent studies cedure may therefore decrease.
have shown that with immediate implant placement it is beneficial The least ideal time for soft tissue augmentation is following
to use a connective tissue graft to thicken the buccal contour. This insertion of the final reconstruction. This time point is not con-
allows for a change of the phenotype at the implant site and lim- sidered as part of the treatment plan and is usually performed to
56,57,66
its the development of recession and esthetic deficiencies. compensate for severe tissue deficiencies. It can be regarded as a
A systematic review analyzed soft tissue augmentation procedures “rescue treatment,” is associated with decreased predictability, and
performed during abutment connection surgery. 20 It was concluded is highly technique-­sensitive.54,59 Quite often, the restoration needs
that, for the increase of peri-­implant attached and keratinized tissue, to be removed to perform the augmentation surgery. This creates
128 | THOMA et al.

13. Souza AB, Tormena M, Matarazzo F, Araujo MG. The influence of

an additional need to provide the patient with a temporary solution, peri-­implant keratinized mucosa on brushing discomfort and peri-­
thereby increasing the treatment costs and time. implant tissue health. Clin Oral Implants Res. 2016;27:650-­655.
14. Brandenberg FD, Sailer I, Fehmer V, Büchi DL, Hämmerle CH,
Thoma DS. Randomized controlled clinical pilot study of all-­
ceramic single-­tooth implant reconstructions: clinical and micro-
7 | CO N C LU S I O N biological outcomes at one year of loading. Clin Oral Implants Res.
2017;28:406-­413.
The quality and quantity of peri-­
implant soft tissues are crucial 15. Ioannidis A, Cathomen E, Jung RE, Fehmer V, Husler J, Thoma DS.
factors and significantly influence biologic and esthetic outcomes Discoloration of the mucosa caused by different restorative mate-
rials -­a spectrophotometric in vitro study. Clin Oral Implants Res.
in implant dentistry. A proper risk assessment and management of
2017;28:1133-­1138.
the soft tissues at the planned implant site is important prior to any 16. Zucchelli G, Mazzotti C, Mounssif I, Mele M, Stefanini M,
implant-­related surgery. In cases of soft tissue deficiencies, these Montebugnoli L. A novel surgical-­prosthetic approach for soft tis-
should be addressed as early as possible to increase the predictabil- sue dehiscence coverage around single implant. Clin Oral Implants
Res. 2013;24:957-­962.
ity of the surgical interventions.
17. Roccuzzo M, Grasso G, Dalmasso P. Keratinized mucosa around
implants in partially edentulous posterior mandible: 10-­year re-
AC K N OW L E D G M E N T sults of a prospective comparative study. Clin Oral Implants Res.
Open Access Funding provided by Universitat Zurich. 2016;27:491-­496.
18. Thoma DS, Zeltner M, Hilbe M, Hammerle CH, Husler J, Jung RE.
Randomized controlled clinical study evaluating effectiveness and
REFERENCES safety of a volume-­stable collagen matrix compared to autogenous
1. Jung RE, Zembic A, Pjetursson BE, Zwahlen M, Thoma DS. connective tissue grafts for soft tissue augmentation at implant
Systematic review of the survival rate and the incidence of biolog- sites. J Clin Periodontol. 2016;43:874-­885.
ical, technical, and aesthetic complications of single crowns on im- 19. Thoma DS, Buranawat B, Hammerle CH, Held U, Jung RE. Efficacy
plants reported in longitudinal studies with a mean follow-­up of 5 of soft tissue augmentation around dental implants and in par-
years. Clin Oral Implants Res. 2012;23(Suppl 6):2-­21. tially edentulous areas: a systematic review. J Clin Periodontol.
2. Pjetursson BE, Thoma D, Jung R, Zwahlen M, Zembic A. A sys- 2014;41(Suppl 15):S77-­91.
tematic review of the survival and complication rates of implant-­ 20. Bassetti RG, Stahli A, Bassetti MA, Sculean A. Soft tissue augmen-
supported fixed dental prostheses (FDPs) after a mean observation tation procedures at second-­stage surgery: a systematic review.
period of at least 5 years. Clin Oral Implants Res. 2012;23(Suppl Clin Oral Investig. 2016;20:1369-­1387.
6):22-­38. 21. Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B,
3. Albrektsson T, Buser D, Sennerby L. On crestal/marginal bone Thomsen P. The soft tissue barrier at implants and teeth. Clin Oral
loss around dental implants. Int J Periodontics Restorative Dent. Implants Res. 1991;2:81-­90.
2013;33:9-­11. 22. Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of the
4. Benic GI, Hämmerle CH. Horizontal bone augmentation by means vascular systems in the periodontal and peri-­implant tissues in the
of guided bone regeneration. Periodontol 2000. 2014;66(1):13–­4 0. dog. J Clin Periodontol. 1994;21:189-­193.
5. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone thick- 23. Moon IS, Berglundh T, Abrahamsson I, Linder E, Lindhe J. The
ness on facial marginal bone response: stage 1 placement through barrier between the keratinized mucosa and the dental im-
stage 2 uncovering. Ann Periodontol. 2000;5:119-­128. plant. An experimental study in the dog. J Clin Periodontol.
6. De Bruyn H, Vandeweghe S, Ruyffelaert C, Cosyn J, Sennerby L. 1999;26:658-­6 63.
Radiographic evaluation of modern oral implants with emphasis on 24. Salvi GE, Aglietta M, Eick S, Sculean A, Lang NP, Ramseier CA.
crestal bone level and relevance to peri-­implant health. Periodontol Reversibility of experimental peri-­ implant mucositis compared
2000. 2013;62(1):256–­270. with experimental gingivitis in humans. Clin Oral Implants Res.
7. Sennerby L, Meredith N. Implant stability measurements using res- 2012;23:182-­190.
onance frequency analysis: biological and biomechanical aspects 25. Nemcovsky CE, Moses O, Rotated palatal flap. A surgical approach
and clinical implications. Periodontol 2000. 2008;47(1):51–­66. to increase keratinized tissue width in maxillary implant uncover-
8. Zigdon H, Machtei EE. The dimensions of keratinized mucosa ing: technique and clinical evaluation. Int J Periodontics Restorative
around implants affect clinical and immunological parameters. Clin Dent. 2002;22:607-­612.
Oral Implants Res. 2008;19:387-­392. 26. Sanz M, Chapple IL, Working Group 4 of the VEWoP. Clinical re-
9. Benic GI, Mokti M, Chen CJ, Weber HP, Hammerle CH, Gallucci search on peri-­ implant diseases: consensus report of Working
GO. Dimensions of buccal bone and mucosa at immediately placed Group 4. J Clin Periodontol. 2012;39(Suppl 12):202-­206.
implants after 7 years: a clinical and cone beam computed tomog- 27. Lee CT, Huang YW, Zhu L, Weltman R. Prevalences of peri-­
raphy study. Clin Oral Implants Res. 2012;23:560-­566. implantitis and peri-­implant mucositis: systematic review and meta-­
10. Jung RE, Fenner N, Hämmerle CH, Zitzmann NU. Long-­term out- analysis. J Dent. 2017;62:1-­12.
come of implants placed with guided bone regeneration (GBR) using 28. Thoma DS, Naenni N, Figuero E, et al. Effects of soft tissue aug-
resorbable and non-­resorbable membranes after 12–­14 years. Clin mentation procedures on peri-­implant health or disease: A system-
Oral Implants Res. 2013;24:1065-­1073. atic review and meta-­analysis. Clin Oral Implants Res. 2018;29(Suppl
11. Brito C, Tenenbaum HC, Wong BK, Schmitt C, Nogueira-­Filho G. Is 15):32-­49.
keratinized mucosa indispensable to maintain peri-­implant health? 29. Hämmerle CH, Araujo MG, Simion M, Osteology Consensus G.
A systematic review of the literature. J Biomed Mater Res B Appl Evidence-­based knowledge on the biology and treatment of ex-
Biomater. 2014;102:643-­650. traction sockets. Clin Oral Implants Res. 2012;23(Suppl 5):80-­82.
12. Lin GH, Chan HL, Wang HL. The significance of keratinized 30. Avila-­Ortiz G, Elangovan S, Kramer KW, Blanchette D, Dawson DV.
mucosa on implant health: a systematic review. J Periodontol. Effect of alveolar ridge preservation after tooth extraction: a sys-
2013;84:1755-­1767. tematic review and meta-­analysis. J Dent Res. 2014;93:950-­958.
THOMA et al. | 129

31. Jung RE, Ioannidis A, Hammerle CHF, Thoma DS. Alveolar 50. Kohal RJ, Att W, Bachle M, Butz F. Ceramic abutments and ceramic
ridge preservation in the esthetic zone. Periodontol 2000. oral implants. An Update. Periodontol 2000. 2008;47(1):224–­243.
2018;77(1):165–­175. 51. Evans CD, Chen ST. Esthetic outcomes of immediate implant place-
32. Araujo MG, Silva CO, Misawa M, Sukekava F. Alveolar socket heal- ments. Clin Oral Implants Res. 2008;19:73-­8 0.
ing: what can we learn? Periodontol 2000. 2015;68(1):122–­134. 52. Burkhardt R, Andreoni C, Marinello CP. Psychological and social
33. Wennström JL, Derks J. Is there a need for keratinized mucosa effects of implant supported reconstructions. ACTA Medicinae
around implants to maintain health and tissue stability? Clin Oral Dentium Helvetica. 2000;5:1-­8.
Implants Res. 2012;23(Suppl 6):136-­146. 53. Burgers R, Gerlach T, Hahnel S, Schwarz F, Handel G, Gosau M. In
34. Furhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. vivo and in vitro biofilm formation on two different titanium im-
Evaluation of soft tissue around single-­tooth implant crowns: the plant surfaces. Clin Oral Implants Res. 2010;21:156-­164.
pink esthetic score. Clin Oral Implants Res. 2005;16:639-­6 44. 54. Burkhardt R, Joss A, Lang NP. Soft tissue dehiscence coverage
35. Jung RE, Sailer I, Hammerle CH, Attin T, Schmidlin P. In vitro around endosseous implants: a prospective cohort study. Clin Oral
color changes of soft tissues caused by restorative materials. Int J Implants Res. 2008;19:451-­457.
Periodontics Restorative Dent. 2007;27:251-­257. 55. Cornelini R, Barone A, Covani U. Connective tissue grafts in postex-
36. Nisapakultorn K, Suphanantachat S, Silkosessak O, traction implants with immediate restoration: a prospective con-
Rattanamongkolgul S. Factors affecting soft tissue level around trolled clinical study. Pract Proced Aesthet Dent. 2008;20:337-­3 43.
anterior maxillary single-­ tooth implants. Clin Oral Implants Res. 56. Cosyn J, Eghbali A, Hermans A, Vervaeke S, De Bruyn H, Cleymaet
2010;21:662-­670. R. A 5-­year prospective study on single immediate implants in the
37. Khzam N, Arora H, Kim P, Fisher A, Mattheos N, Ivanovski S. aesthetic zone. J Clin Periodontol. 2016;43:702-­709.
Systematic review of soft tissue alterations and esthetic outcomes 57. Zuiderveld EG, Meijer HJA, den Hartog L, Vissink A, Raghoebar
following immediate implant placement and restoration of single GM. Effect of connective tissue grafting on peri-­ implant tis-
implants in the anterior maxilla. J Periodontol. 2015;86:1321-­1330. sue in single immediate implant sites: A RCT. J Clin Periodontol.
38. Oates TW, West J, Jones J, Kaiser D, Cochran DL. Long-­ term 2018;45:253-­264.
changes in soft tissue height on the facial surface of dental im- 58. Schneider D, Grunder U, Ender A, Hammerle CH, Jung RE. Volume
plants. Implant Dent. 2002;11:272-­279. gain and stability of peri-­implant tissue following bone and soft tis-
39. Sicilia A, Botticelli D, Working G. Computer-­guided implant ther- sue augmentation: 1-­year results from a prospective cohort study.
apy and soft-­and hard-­tissue aspects. The Third EAO Consensus Clin Oral Implants Res. 2011;22:28-­37.
Conference 2012. Clin Oral Implant Res. 2012;6:157-­161. 59. Roccuzzo M, Gaudioso L, Bunino M, Dalmasso P. Surgical treat-
40. Gobbato L, Avila-­ O rtiz G, Sohrabi K, Wang CW, Karimbux ment of buccal soft tissue recessions around single implants: 1-­
N. The effect of keratinized mucosa width on peri-­ i mplant year results from a prospective pilot study. Clin Oral Implants Res.
health: a systematic review. Int J Oral Maxillofac Implants. 2014;25:641-­6 46.
2013;28:1536-­1545. 60. Rotundo R, Pagliaro U, Bendinelli E, Esposito M, Buti J. Long-­term
41. Tomasi C, Tessarolo F, Caola I, Wennstrom J, Nollo G, Berglundh T. outcomes of soft tissue augmentation around dental implants on
Morphogenesis of peri-­implant mucosa revisited: an experimental soft and hard tissue stability: a systematic review. Clin Oral Implants
study in humans. Clin Oral Implants Res. 2014;25:997-­1003. Res. 2015;26(Suppl 11):123-­138.
42. Vandeweghe S, De Bruyn H. A within-­implant comparison to eval- 61. Chambrone L, Tatakis DN. Periodontal soft tissue root cover-
uate the concept of platform switching: a randomised controlled age procedures: a systematic review from the AAP Regeneration
trial. Eur J Oral Implantol. 2012;5:253-­262. Workshop. J Periodontol. 2015;86:S8-­51.
43. Windisch SI, Jung RE, Sailer I, Studer SP, Ender A, Hammerle CH. A 62. Jung RE, Holderegger C, Sailer I, Khraisat A, Suter A, Hammerle CH.
new optical method to evaluate three-­dimensional volume changes The effect of all-­ceramic and porcelain-­fused-­to-­metal restorations
of alveolar contours: a methodological in vitro study. Clin Oral on marginal peri-­implant soft tissue color: a randomized controlled
Implants Res. 2007;18:545-­551. clinical trial. Int J Periodontics Restorative Dent. 2008;28:357-­365.
44. van Brakel R, Cune MS, van Winkelhoff AJ, de Putter C, Verhoeven 63. Landsberg CJ, Bichacho N. A modified surgical/prosthetic approach
JW, van der Reijden W. Early bacterial colonization and soft tissue for optimal single implant supported crown. Part I-­The socket seal
health around zirconia and titanium abutments: an in vivo study in surgery. Pract Periodontics Aesthet Dent. 1994;6:11-­17. quiz 19.
man. Clin Oral Implants Res. 2011;22:571-­577. 64. Jung RE, Siegenthaler DW, Hammerle CH. Postextraction tis-
45. Suarez-­Lopez Del Amo F, Lin GH, Monje A, Galindo-­Moreno P, sue management: a soft tissue punch technique. Int J Periodontics
Wang HL. Influence of soft tissue thickness on peri-­implant mar- Restorative Dent. 2004;24:545-­553.
ginal bone loss: a systematic review and meta-­analysis. J Periodontol. 65. Stimmelmayr M, Allen EP, Reichert TE, Iglhaut G. Use of a combi-
2016;87:690-­699. nation epithelized-­subepithelial connective tissue graft for closure
46. Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of soft and soft tissue augmentation of an extraction site following ridge
tissue thickness on crestal bone changes around implants: a 1-­year preservation or implant placement: description of a technique. Int J
prospective controlled clinical trial. Int J Oral Maxillofac Implants. Periodontics Restorative Dent. 2010;30:375-­381.
2009;24:712-­719. 66. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-­
47. Puisys A, Linkevicius T. The influence of mucosal tissue thickening implant mucosa: an evaluation of maxillary anterior single implants
on crestal bone stability around bone-­level implants. A prospective in humans. J Periodontol. 2003;74:557-­562.
controlled clinical trial. Clin Oral Implants Res. 2015;26:123-­129.
48. Bengazi F, Wennström JL, Lekholm U. Recession of the soft tissue
margin at oral implants. A 2-­year longitudinal prospective study.
How to cite this article: Thoma DS, Gil A, Hämmerle CHF,
Clin Oral Implants Res. 1996;7:303-­310.
Jung RE. Management and prevention of soft tissue
49. Glauser R, Sailer I, Wohlwend A, Studer S, Schibli M, Scharer P.
Experimental zirconia abutments for implant-­ supported single-­ complications in implant dentistry. Periodontol 2000.
tooth restorations in esthetically demanding regions: 4-­year results 2022;88:116–­129. doi:https://doi.org/10.1111/prd.12415
of a prospective clinical study. Int J Prosthodont. 2004;17:285-­290.