CLINICAL

Minimally Invasive Treatment of Soft Tissue Deficiency

Around an Implant-Supported Restoration in the Esthetic
Zone: Modified VISTA Technique Case Report
Chun-Teh Lee, DDS, MS1
Techkouhie Hamalian, DDS, MS2
Ulrike Schulze-Späte, DDS, PhD1*

The horizontal and vertical soft tissue dimension around an implant-supported restoration in the maxillary anterior is one of the
determining factors for achieving an esthetic result. In this case report, the patient presented with a deficiency in both dimensions around
a single-tooth implanted-supported restoration in the anterior maxilla. The soft tissue defects were augmented with a connective tissue
graft that was placed underneath the buccal peri-implant tissue using a frenum access incision and a supraperiosteal tunneling approach
(modified vestibular Incision supraperiosteal tunnel access [VISTA] technique). This novel technique resulted in an increase in tissue height
and width, which suggests its potential use around implant-supported restorations.

Key Words: soft tissue augmentation, recession, dental implant, soft tissue deficiency

INTRODUCTION ratio.7 The appearance of soft tissue around implant-supported

restorations has been compared with that of scar tissue that

T
reating a soft tissue defect around an implant-
forms after a surgical intervention,1 and its structural support
supported restoration in the esthetic zone is still a
and vascularization come solely from underlying bone. Soft
challenging problem for today‘s clinicians. So far, there
tissue around natural teeth is characterized by supracrestal
is no predictable way of correcting a soft tissue defect
fibers that insert into the cementum, high vascularity,
around an implant-supported crown. Currently, only one
periodontal ligament space, and alveolar bone where peri-
prospective cohort study1 and a couple of case reports2,3
odontal fibers are inserting. In addition, cementum is more
describe successful treatment of soft tissue defects around
biocompatible than metal abutments or porcelain crowns and,
implant-supported restorations. Burkhardt et al1 treated 10
therefore, soft tissue can form connective attachment8 to a
patients with mucosal defects around implant-supported
tooth instead of only a long junctional epithelium.9 All this
restorations in the maxillary anterior with coronally advanced
might explain the challenge associated with successful soft
flaps in combination with connective tissue grafts.
tissue grafting around dental implants because structural
Over the course of 6 months, soft tissue thickness and initial
support and vascularization are prerequisites for achieving a
recession coverage decreased from 75% to 66%. In contrast,
sufficient amount of augmentation.
performing the same procedure on natural teeth can achieve
Zadeh10 described a surgical flap technique for root
78% to 89% root coverage.4,5 These numbers demonstrate that
coverage around maxillary teeth called VISTA (vestibular
a connective tissue graft in combination with a coronally
incision subperiostal tunnel approach). A midline frenum access
advanced flap around implant-supported restorations is not as
incision is used to access the buccal tissue and prepare a
successful as it would be around natural teeth.
tunnel. This tunnel preparation toward the gingival margin of
Several factors might negatively influence healing around
the maxillary anterior teeth releases flap tension, preserves
implant-supported restorations after soft tissue grafting. For
vascularization, and, therefore, might positively affect clinical
example, there are structural differences between soft tissue
outcome.11 A graft can be placed through the frenum incision
around dental implants and natural teeth. In comparison to
line underneath the flap and moved coronally to cover the
healthy tissue around teeth, soft tissue around dental implants
recession. Because a conventional tunneling approach uses
has decreased vascularity6 and a reduced collagen to fibroblast
only a small intrasulcular incision, through which the soft tissue
graft can be placed, the access through a frenum incision is
1
Division of Periodontology, Department of Oral Medicine, Infection and broader and might, therefore, result in less trauma to the soft
Immunity, Harvard School of Dental Medicine, Boston, Mass. tissue collar due to tearing of the sulcular tissue.
2
Division of Prosthodontics, Section of Oral and Diagnostic Sciences,
College of Dental Medicine, Columbia University, New York, NY.
Taking into account the nature of soft tissue around
* Corresponding author, e-mail: [email protected] implant-supported restorations, we altered this minimally
DOI: 10.1563/AAID-JOI-D-13-00043 invasive technique and used it to address a soft tissue defect

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Modified VISTA Technique Around an Implant-Supported Restoration

FIGURES 1 AND 2. FIGURE 1. (a) Patient presents with a high smile showing all gingival margins and papillae. (b and c) The left upper maxillary
incisor (#9) had a fistula and a horizontal fracture (periapical radiograph). Keratinized tissue was approximately 4 mm wide, and the
patient‘s periodontal tissue type was determined to be thin. In addition, #9 had a facial recession of 0.5 mm.The papilla between #8 and #9
was slightly deficient due to interproximal bone loss visible on the periapical radiograph. FIGURE 2. Clinical presentation before soft tissue
augmentation. (a) Before the modified VISTA (vestibular incision subperiostal tunnel approach) procedure, the gingival margin was more
than 1 mm apical to the margin of the adjacent tooth. (b) The horizontal tissue dimension was reduced and appeared sunken in, especially
in the coronal aspect. Both deficiencies were severe enough to be noticeable when the patient smiled.

around an implant-supported restoration. Furthermore, we flap, the socket was sealed with a free gingival graft as
modified VISTA to a supraperiosteal flap design instead of the previously described by Landsberg et al.13 This technique
original full-thickness approach and combined it with a facilitates closure after tooth extraction without changing the
connective tissue grafting procedure to augment deficient soft original location of the mucogingival junction. The #9 space
tissue around an implant-supported restoration. In the current was temporally restored using the natural crown of #9, which
case report, we describe the surgical and restorative steps was connected to teeth #8 and #10 using Ribbond lingual mesh
associated with the treatment. (Ribbond, Seattle, Wash) and flowable composite (shade A2,
Filtek Supreme Ultra Flowable Restorative Refill, 3M ESPE). To
avoid interferences during wound healing, the cervical part of
CASE REPORT AND MATERIAL AND METHODS the previous crown was reduced to leave a vertical space of 1–2
Initial surgical and restorative phase mm.
The patient was seen 1 week after the procedure to
A 25-year-old woman presented for evaluation of tooth #9 in reinforce the composite bonding. During subsequent visits,
June 2010. The patient was systemically healthy, was a additional composite was added underneath the pontic and
nonsmoker, and had a high smile line (Figure 1a). Tooth #9 the vertical gap between the edentulous ridge, and the bonded
had been endodontically treated after sustaining a trauma in tooth crown was filled in. Seven months after socket
2007. A fistula on the buccal of #9 developed during the preservation, a dental implant was placed (Osseotite Tapered
following months, and the root canal was subsequently Certain 4 3 10 mm, Biomet 3i, Palm Beach Gardens, Fla). At this
retreated. However, the fistula remained, and examination time, the interdental papilla had receded 1 mm, and a
using gutta percha markings and a periapical radiograph reduction of the horizontal tissue dimension (1–2 mm) was
revealed a horizontal fracture (Figure 1a and c). Because of the detected on the facial aspect. To compensate for the horizontal
apical location of the fracture line, the tooth was deemed tissue loss, the facial area was augmented with a xenograft
nonrestorable, and it was decided to replace it with an implant- (Endobon, Biomet 3i), and the graft particles were covered with
supported restoration. a collagen membrane (Dynamatrix Extracelluar membrane,
An atraumatic flapless extraction was performed to Keystone Dental). Because the grafted area did not extend
preserve tooth-supporting bone. Nevertheless, a large buccal toward the coronal part of the ridge and the implant had been
fenestration (around 4 mm 3 6 mm) was detected in the area of placed with a torque .40 Ncm, an immediate temporary
the previous fistula. The extraction socket was grafted with an restoration was placed.
allograft (FDBA, AlloGraft cancellous, Straumann, Andover, MA). For this purpose, a hexed open-tray impression coping
The lesion within the socket and the socket orifice were (Certain EP Pick-Up Coping [Non-Hexed] 4.1 mm (D) 3 4.1 mm
covered with a collagen membrane (Dynamatrix Extracelluar [P], Biomet 3i) was screwed into the implant and an impression
membrane, Keystone Dental, Burlington, Mass).12 To achieve was taken using interocclusal record material (Blue-mousse
primary flap closure without releasing a facial mucogingival Impression Material, Parkell, Edgewood, NY). A screw-retained

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 Lee et al

temporary was fabricated in the laboratory using a PEEK were tightened in the middle of the buccal gingiva instead of
(polyetheretherketone) abutment (Certain PreFormance Tem- the interdental gingiva to secure the underlying graft. The graft
porary Cylinder [Hexed] 4.1 mm (D), Biomet 3i) as a base. The was left partially exposed in the frenectomy area (Figure 3d).
provisional restoration was adjusted to avoid all centric and The patient was given pain medication (ibuprofen 800 mg,
eccentric contacts. Furthermore, the profile on the labial 1 tablet every 8 hours as need for pain) and was asked to rinse
abutment surface was kept flat to concave to encourage tissue with 0.5 oz of Peridex Chlorhexidine Gluconate 0.12% (3M ESPE)
growth into a more coronal position. Also, the subgingival for 30 seconds twice a day until the follow up appointment 1
profile in the interproximal space between #8 and #9 was made week later. In addition, the patient was instructed to eat a soft
more convex to mold the tissue toward the proximal surface of diet and not to pull on her upper lip. Brushing in this area was
the adjacent tooth and, therefore, move the currently deficient restricted for 3 weeks.
papilla coronally. The patient came back for follow up at 1, 2, 4, 6, 12, and 24
The patient presented for a follow-up appointment 1 week weeks (Figure 5a). Soft tissue dimension was stable during
after surgery and every 2 weeks subsequently to control plaque those 6 months. Six months after the surgical procedure, an
accumulation and observe the progress in healing. Six months implant level impression (open tray hexed 4.1 mm engaging
after implant placement, the soft tissue had receded approx- impression coping, BioMet 3i) was taken to fabricate the final
imately 1 mm on the facial aspect of the crown, and the restoration in the laboratory. After evaluating study models,
horizontal tissue dimension was still insufficient in the implant angulation and soft tissue thickness (.3 mm), it was
previously grafted area (Figure 2a and b). Keratinized tissue decided to fabricate a porcelain-fused to metal crown
was approximately 4 mm wide, and the patient‘s periodontal cemented on a hexed type IV gold custom abutment. During
tissue type was determined to be thin.14 Periodontal probing of subsequent appointments, the abutment was tried in to verify
the neighboring teeth revealed readings in the a 1–2 mm range that its margins were located 1 mm subgingivally (Figure 5b
and no bleeding on probing. Because the patient had a high and c). Using a manual prosthetic wrench, the custom
smile line, both tissue defects were visible when the patient abutment was torqued to 20 Ncm following the manufacturer’s
smiled. Therefore, it was decided to further augment the soft recommendation. During subsequent visits, the crown was
tissue before placing a permanent restoration. evaluated until shape, color, and tissue appearance were
satisfactory. At this point, the crown was cemented using
Soft tissue augmentation using modified VISTA technique Temp-bond temporary cement (Kerr, Orange, Calif).
After insertion, the patient was seen for follow-up visits to
To facilitate the grafting procedure, the contour and length of
check tissue health and occlusion. One year after soft tissue
the temporary crown needed to be adjusted before surgery.
augmentation and 4 months after crown placement, tissue
The artificial cement enamel junction (CEJ) was moved 2 mm
levels remained stable (Figure 6). We offered to perform
coronally to the CEJ of the adjacent teeth and contour of the
gingivoplasty on the site to further improve the color match to
temporary abutment below that artificial CEJ was kept flat to
#8. The patient declined. She was satisfied with the esthetic
allow for good flap adaptation. The area was anesthetized with
result.
lidocaine 2% 1:100 000 epinephrine and marcaine 0.5%
1:200 000 epinephrine using local infiltration. A frenectomy
was performed with a triangular incision using a scalpel with a
DISCUSSION
15c blade (Figures 3a and 4a).
The resulting tissue opening was used to access the facial Maxillary implant placement in patients with a high smile line is
area and to prepare a split-thickness flap using an Allen end challenging because of esthetic considerations. We used soft
cutting intrasulcular knife (Hu-Friedy, Chicago, IL) and an Allen tissue grafting to treat a soft tissue deficiency around a single
modified Orban knife (Hu-Friedy) (Figures 3b and 4b). The implant-supported restoration. The original tooth had been
dissection tunnel was extended toward the gingival sulcus ,and removed atraumatically without raising a mucogingival flap.
care was taken not to perforate the flap. Periosteum was left This extraction technique might cause less soft tissue recession
intact on the bony surface of the facial plate to protect the and subsequent change in ridge dimensions than elevating a
previously placed graft material and to provide better facial flap.17 It has been shown in previous studies that flap
vascularity.15 To mobilize the flap, the tunnel was extended elevation can cause bone resorption18 and concomitant soft
toward the lateral incisor. Afterward, we used a periodontal tissue recession.19 Nevertheless, in the patient in the present
probe to test whether the flap could be easily moved 2 mm case, the mesial papilla of #9 receded 1 mm and the soft tissue
more coronally than the CEJ of adjacent teeth to allow for on the buccal aspect of #9 lost 2 mm in the horizontal
overbuilding soft tissue. dimension after tooth extraction and simultaneous socket
After preparing the recipient bed, a connective tissue graft grafting. The compromised horizontal tissue dimension was
was harvested from the palate using a 2-incision technique.16 especially visible when the patient smiled as it affected tissue
Measurements of the graft took into consideration the amount coloration.
of recession and adjusted for sufficient overlap to the lateral While placing a dental implant, guided bone regeneration
into the papilla area. The graft was placed underneath the was performed to augment the horizontal dimension and
tunnel flap and stabilized with interrupted sutures (Vicryl 5-0, address the loss of ridge width. A temporary crown was
Ethicon) on the periosteum (Figure 3c). Afterward, the split delivered to support the coronal soft tissue. The crown was
thickness flap was advanced 2 mm coronal to the CEJ of the adjusted during healing to improve soft tissue contour.
adjacent teeth with a modified sling suture (Vicryl 5-0). Knots Adjusting the critical contour (area close to gingival margin)

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Modified VISTA Technique Around an Implant-Supported Restoration

FIGURE 3. Modified VISTA (vestibular incision subperiostal tunnel approach) soft tissue augmentation procedure. (a) A frenectomy was
performed with a triangular incision using a scalpel with a 15c blade. (b) The buccal area was accessed through the frenum incision in the
vestibule, and a split thickness tunnel flap was prepared. The tunnel flap extended toward the gingival sulcus and the lateral incisor. (c) A
connective tissue was harvested and placed underneath the split thickness flap envelope. (d) The connective graft was stabilized with
interrupted sutures, and the mucogingival flap was advanced coronally.

and subcritical contour (area apical to the critical contour) by dissecting the frenum is less technique sensitive than
during the healing phase can improve soft tissue appearance, preparing a tunnel flap from the sulcus because of the thick
whereas inappropriate contours of a temporary crown may fibrous tissue of the frenum and accessibility of the area. In
cause further soft tissue recession.20 However, despite con- contrast to the original VISTA flap technique, we prepared a
touring the temporary restoration and augmenting the facial split thickness tunnel flap instead of a full thickness subper-
area, the horizontal tissue dimension remained compromised, iosteum tunnel flap.10 The split thickness flap did not interfere
and the gingival margin remained 1 mm apical to the margin of with the previously placed graft and might have prevented
#8. Both deficiencies were severe enough to be noticeable further bone loss by leaving the periosteum intact and,
when the patient smiled. Therefore, a soft tissue augmentation therefore, preserving vascularity.15
procedure was planned to correct those defects before a We used the patient’s own connective tissue for this
permanent implant-supported restoration was fabricated. grafting procedure. Connective tissue is an established
We selected the VISTA technique, which had been originally treatment option for general root coverage.5 Criticism usually
used for the treatment of root recession, and customized it to involves patient discomfort and tissue morbidity due to tissue
address the specific soft tissue defects in our patient. The harvest from a second surgical site. Therefore, Mareque-Bueno3
technique has several advantages over a conventional tunnel- used acellular dermal matrix and a coronally advanced flap to
ing approach. Entering the surgical site through the vestibule graft a recession around an implant-supported restoration. Six

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 Lee et al

FIGURES 4–6. FIGURE 4. (a) Before the start of the surgical procedure, the cement enamel junction of the crown was moved 2 mm coronally
and the crown profile was flattened to create additional space for the advancement of the flap. A frenectomy was performed with a
triangular incision using a scalpel with a 15c blade. (b) Using an Allen end cutting intrasulcular knife, the buccal area was accessed and a
split thickness tunnel flap was prepared. FIGURE 5. Healing after soft tissue augmentation and prosthetic phase. (a) The patient was seen 6
months after soft tissue augmentation. The picture depicts uneventful healing and a stable gingival margin. (b and c) The final abutment
was tried in and the fit verified. FIGURE 6. Follow-up after placement of final restoration (frontal and occlusal view). (a and b) The patient
was seen 1 year after soft tissue augmentation and 4 months after crown placement. The gingival margins remained stable. The overall
soft tissue architecture was now close to the one before removal of tooth #9.

months after the procedure, 67% of the recession was covered. contact points of the temporary crown were continuously
Nevertheless, in the current patient we used a connective tissue adjusted, and an additional increase in papilla height (around
graft as previous studies showed that acellular dermal matrix 0.5 mm) was measured. It has to be taken into account, that
can shrink significantly over time, resulting in a recurring one of the most determining factors in papilla presence and
recession during long term follow-up.21 height is the amount of interproximal bone. This dictates, and
Immediately after surgery, we detected an increase in the might therefore limit, the amount of papilla regeneration.22,23
soft tissue horizontal dimension by 1–2 mm (within 5 mm from Several publications used placement of connective tissue
the gingival margin). During the healing phase, contour and grafts at different stages of implant therapy to increase and

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Modified VISTA Technique Around an Implant-Supported Restoration

preserve horizontal tissue dimensions. Grunder24 showed that attachment of human gingiva to titanium in vivo. J Prosthet Dent. 1984;52:
buccal placement of connective tissue at the time of immediate 418–420.
10. Zadeh HH. Minimally invasive treatment of maxillary anterior
implant placement can increase horizontal soft tissue dimen- gingival recession defects by vestibular incision subperiosteal tunnel access
sion by 1 mm in comparison with a control group. Burkhardt et and platelet-derived growth factor BB. Int J Periodontics Restorative Dent.
al1 evaluated recession coverage around implant-supported 2011;31:653–660.
restorations 6 months after a conventional coronally advanced 11. Pini Prato G, Pagliaro U, Baldi C, et al. Coronally advanced flap
procedure for root coverage. Flap with tension versus flap without tension: a
flap in combination with a connective tissue graft. They randomized controlled clinical study. J Periodontol. 2000;71:188–201.
detected that an average of 2/3 of the original recession was 12. Elian N, Cho SC, Froum S, Smith RB, Tarnow DP. A simplified socket
covered. In line with these studies, Schneider et al25 and Lee et classification and repair technique. Pract Proced Aesthet Dent. 2007;19:99–
al25 used soft tissue grafting at dental implant sites immediately 104; quiz 106.
13. Landsberg CJ. Implementing socket seal surgery as a socket
at the time of placement or at the second-stage procedure
preservation technique for pontic site development: surgical steps
when a healing abutment was attached to improve soft tissue revisited—a report of two cases. J Periodontol. 2008;79:945–954.
architecture. Stability of the gingival level27–29 and the changes 14. De Rouck T, Eghbali R, Collys K, De Bruyn H, Cosyn J. The gingival
in soft tissue dimensions30 after crown delivery are similar to biotype revisited: transparency of the periodontal probe through the
that of other reports. There is still a slight deficiency of the gingival margin as a method to discriminate thin from thick gingiva. J Clin
Periodontol. 2009;36:428–433.
mesial papilla height. However, the overall soft tissue 15. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting
architecture was very close to the pre-extraction situation, for root coverage. I. Rationale and technique. Int J Periodontics Restorative
and the patient was very satisfied with the clinical outcome. Dent. 1994;14:216–227.
16. Bruno JF. Connective tissue graft technique assuring wide root
coverage. Int J Periodontics Restorative Dent. 1994;14:126–137.
17. Fickl S, Zuhr O, Wachtel H, Kebschull M, Hurzeler MB. Hard tissue
CONCLUSION alterations after socket preservation with additional buccal overbuilding: a
study in the beagle dog. J Clin Periodontol. 2009;36:898–904.
Modification of the VISTA technique seems to be a promising 18. Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. Alveolar crest
method for enhancing soft tissue dimensions around implant- reduction following full and partial thickness flaps. J Periodontol. 1972;43:
supported restoration in the anterior maxilla. 141–144.
19. Gomez-Roman G. Influence of flap design on peri-implant
interproximal crestal bone loss around single-tooth implants. Int J Oral
Maxillofac Implants. 2001;16:61–67.
ABBREVIATIONS 20. Su H, Gonzalez-Martin O, Weisgold A, Lee E. Considerations of
implant abutment and crown contour: critical contour and subcritical
CEJ: cement enamel junction contour. Int J Periodontics Restorative Dent. 2010;30:335–343.
VISTA: vestibular incision supraperiosteal tunnel access 21. Harris RJ. A short-term and long-term comparison of root coverage
with an acellular dermal matrix and a subepithelial graft. J Periodontol. 2004;
75:734–743.
22. Grunder U. Stability of the mucosal topography around single-
ACKNOWLEDGMENT tooth implants and adjacent teeth: 1-year results. Int J Periodontics
Restorative Dent. 2000;20:11–17.
We want to thank Eric Ku for preparing the illustration. 23. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP,
Malevez C. Clinical and radiographic evaluation of the papilla level adjacent
to single-tooth dental implants. A retrospective study in the maxillary
anterior region. J Periodontol. 2001;72:1364–1371.
REFERENCES
24. Grunder U. Crestal ridge width changes when placing implants at
1. Burkhardt R, Joss A, Lang NP. Soft tissue dehiscence coverage the time of tooth extraction with and without soft tissue augmentation after
around endosseous implants: a prospective cohort study. Clin Oral Implants a healing period of 6 months: report of 24 consecutive cases. Int J
Res. 2008;19:451–457. Periodontics Restorative Dent. 2011;31:9–17.
2. Shibli JA, d’avila S, Marcantonio E Jr. Connective tissue graft to 25. Schneider D, Grunder U, Ender A, Hammerle CH, Jung RE. Volume
correct peri-implant soft tissue margin: A clinical report. J Prosthet Dent. gain and stability of peri-implant tissue following bone and soft tissue
2004;91:119–122. augmentation: 1-year results from a prospective cohort study. Clin Oral
3. Mareque-Bueno S. A novel surgical procedure for coronally Implants Res. 2011;22:28–37.
repositioning of the buccal implant mucosa using acellular dermal matrix: 26. Lee YM, Kim DY, Kim JY, et al. Peri-implant soft tissue level
a case report. J Periodontol. 2011;82:151–156. secondary to a connective tissue graft in conjunction with immediate
4. Wennstrom JL. Mucogingival therapy. Ann Periodontol. 1996;1:671– implant placement: a 2-year follow-up report of 11 consecutive cases. Int J
701. Periodontics Restorative Dent. 2012;32:213–222.
5. Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the 27. Bengazi F, Wennstrom JL, Lekholm U. Recession of the soft tissue
treatment of gingival recession. A systematic review. Ann Periodontol. 2003; margin at oral implants. A 2-year longitudinal prospective study. Clin Oral
8:303–320. Implants Res. 1996;7:303–310.
6. Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of the 28. Small PN, Tarnow DP. Gingival recession around implants: a 1-year
vascular systems in the periodontal and peri-implant tissues in the dog. J longitudinal prospective study. Int J Oral Maxillofac Implants. 2000; 15: 527–
Clin Periodontol. 1994;21:189–193. 532.
7. Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B, 29. Cardaropoli G, Lekholm U, Wennstrom JL. Tissue alterations at
Thomsen P. The soft tissue barrier at implants and teeth. Clin Oral Implants implant-supported single-tooth replacements: a 1-year prospective clinical
Res. 1991;2:81–90. study. Clin Oral Implants Res. 2006;17:165–171.
8. Bruno JF, Bowers GM. Histology of a human biopsy section 30. Jemt T, Lekholm U. Measurements of buccal tissue volumes at
following the placement of a subepithelial connective tissue graft. Int J single-implant restorations after local bone grafting in maxillas: a 3-year
Periodontics Restorative Dent. 2000;20:225–231. clinical prospective study case series. Clin Implant Dent Relat Res. 2003;5:63–
9. Gould TR, Westbury L, Brunette DM. Ultrastructural study of the 70.

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