Received: 7 April 2020 Revised: 1 August 2020 Accepted: 4 August 2020

DOI: 10.1002/JPER.20-0217

H UMAN RANDOMIZED CONTROLLED TRIAL

Effect of connective tissue grafting on buccal bone changes

based on cone beam computed tomography scans in the
aesthetic zone of single immediate implants: A 1-year
randomized controlled trial

Elise G. Zuiderveld1 Wouter G. van Nimwegen1 Henny J.A. Meijer1,2

Ronald E. Jung3 Sven Mühlemann3 Arjan Vissink1 Gerry M. Raghoebar1

1
O artigoDepartment
analisouof Oral and Maxillofacial
o efeito do enxerto
de tecido Surgery, University (ETC)
conjuntivo Medical na
Center
espessura Abstract
da tábua óssea vestibular
GroningenUniversity em implantes
of Groningen, Background: Connective tissue grafting has a beneficial effect on the peri-
imediatos na área estética.
Groningen, The Netherlands
Foram realizados 55 implantes imediatos implant mucosa, but the effect of grafting the buccal mucosa on buccal bone
2 Department
pós extração comof Implant
carga Dentistry,
imediata nas
regiões Dental
entre os University
School, dentes Medical
14 e Center
24. As thickness (BBT) has not been investigated, although BBT is proposed to be a
extrações foram sem retalho e após a
GroningenUniversity of Groningen, key factor for the soft-tissue contour. The aim of this trial was to assess the out-
instalação dos implantes os alvéolos
foram Groningen,
preenchidos The Netherlands
com mistura de come of a connective tissue graft (CTG) in the aesthetic zone of single immediate
3 Cliniceofosso
biomaterial Fixed autógeno.
and Removable
O grupo teste recebeu enxerto de tecido implants on the change of BBT according to cone beam computed tomography
Prosthodontics and Dental Material
conjuntivo removido do túber. Foram
Science, Centerdaof Dental Medicine, (CBCT) scan analysis.
feitas avaliações espessura da tábua
University of Zürich,
óssea vestibular, nívelZürich,
ósseo Switzerland
proximal, Methods: In a 1-year randomized controlled trial, 60 patients received an imme-
altura da mucosa vestibular e fenótipo
gengival através de tomografias nos diately placed implant and provisionalization, either combined with CTG (test
Correspondence
períodos pré operatório e após 1 e 12
Prof. Dr. Henny J.A. Meijer, Department of group) or without CTG (control group). CBCTs were taken pre-operatively (Tpre )
meses seguintes a instalação da coroa.
Oral and Maxillofacial
Os resultados Surgery,que
mostraram University
o ETC and 1 year after definitive restoration (T2 ). Any change in BBT was assessed at
provocou Medical
maiorCenter Groningen,da
redução PO Box 30.001,
espessura
ó s s e a NL-9700
v e s tRBi bGroningen,
u l a r aThep óNetherlands.
s 1 ano, different implant levels. Additionally, the change in mid-buccal mucosal level
provavelmente devido à intervenção
Email: [email protected] (MBML) and approximal marginal bone level were assessed.
cirúrgica com interrupção na

n = 28; control group, n = 27). At T2 , the average change in BBT was significantly
vascularização para colocação do ETC. O Results: Fifty-five patients were available for statistical analysis (test group,
ETC mostrou-se mais determinante para a

larger in the test group (−0.84 ± 0.61 mm) than in the control group (−0.46 ±
perda óssea que o fenótipo gengival. No

0.54 mm, P = 0.02). A MBML gain of 0.07 ± 0.85 mm in the test and a MBML
entanto, o grupo teste apresentou menos
recessão gengival. A altura da margem

loss −0.52 ± 1.16 mm in the control group was observed at T2 . Average loss of
gengival foi melhor preservada quando
se usou ETC. Esse fato talvez seja mais

marginal bone was 0.05 ± 0.33 mm and 0.01 ± 0.38 mm, respectively.
determinante esteticamente.
*Faltou verificar se há ganho de
espessura de tecido mole com o ETC.
Talvez esse aumento seja maior que a Conclusions: The application of CTG in the aesthetic zone of immediately
perda óssea, indicando a técnica, já
que o preenchimento do gap evita placed and provisionalized implants is accompanied with more loss of BBT, but
deiscência óssea e mantem uma espessura at the same time better maintains the mid-buccal mucosal level.
de osso suficiente.

KEYWORDS
@dentalpapers
cone-beam computed tomography, connective tissue, dental implants, single-tooth

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2020 American Academy of Periodontology

J Periodontol. 2020;1–9. wileyonlinelibrary.com/journal/jper 1

2 ZUIDERVELD et al.

1 INTRODUCTION on peri-implant soft and hard tissues. Study set-up was

described in detail by Zuiderveld et al.18 It was approved
Immediate implant placement and provisionalization by the Medical Ethical Committee of the University Medi-
(IIPP) in the aesthetic zone has evolved into a viable cal Center Groningen, The Netherlands, (NL43085.042.13)
opportunity for single-tooth replacement with aesthet- and registered in the trial register (www.trialregister.nl:
ically acceptable results.1–3 However, the mid-buccal NTR3815). This study was conducted in accordance with
mucosa still often recedes.4,5 This recession is presumed to the requirements of the Helsinki Declaration of 1975 and
be most likely a result of the bone remodelling following revised in 2008. Outcomes were reported according to the
tooth extraction, which cannot be prevented through an CONSORT 2010 checklist.20 Written informed consent was
immediately inserted implant.6–8 Such a recession may obtained before enrolling the patients. All patients (aged
lead to a less favourable aesthetic result. ≥18 years) with a single non-restorable tooth in the max-
For reduction of the effects of bone resorption after illofacial aesthetic zone (14 to 24) received an immedi-
tooth removal, it is recommended to position the implant ate implant-supported restoration. Then the patients were
at least 2 mm palatal from the internal buccal socket wall randomly allocated to one of the two study groups by
and the implant-socket gap should be grafted.9 The aim sealed envelopes opened by a research nurse not involved
of the grafting procedure is to create additional amounts in the study just prior to the surgery to either receive a CTG
of peri-implant hard tissue10,11 and is presumed to have a harvested from the tuberosity region or no graft at implant
beneficial outcome for the peri-implant soft tissues.6,12,13 placement.
In addition to grafting the implant-socket gap, thicken-
ing of the peri-implant soft tissues with a connective tis-
sue grafting procedure combined with implant placement 2.2 Patients
is suggested to reduce recession and volume loss of the
mid-buccal mucosa.14,15 Some randomized controlled stud- The following inclusion criteria were used:
ies showed better preservation of the mid-buccal mucosa

wall of <2 mm measured with a periodontal probe,18 ;

in immediate implant cases applying connective tissue - a post-extraction vertical bone defect of the buccal socket
grafting.16–19 Migliorati et al.16 even observed an increase
in mucosal thickness on applying a connective tissue graft - adequate oral hygiene, that is modified plaque and sul-
(CTG). cus bleeding score ≤1 21 ;
We showed a mid-buccal mucosal level preserving - sufficient mesial-distal (≥6 mm) and interocclusal space
effect when applying a CTG simultaneously with an to place an implant-supported crown.
immediately placed and provisionalized implant,18 but
no increase in buccal mucosal volume was observed.19 Exclusion criteria were:
Measuring the change in mid-buccal mucosal volume
does not provide accurate information on changes in the - medical and general contraindications for the surgical
underlying buccal bone thickness (BBT). BBT is proposed procedure, according to the ASA score ≥ III 22,23 ;
to be a key factor that determines the overlying soft-tissue - presence of periodontal disease, expressed by pocket
contour6 and changes in BBT can be considered an probing depths of ≥4 mm and bleeding on probing (mod-
important outcome when predicting aesthetic success. As ified sulcus bleeding index score ≥2);
far as we know, the effect of connective tissue grafting on - smoking;
the change in BBT in the aesthetic zone when combined - history of radiotherapy to the head and neck region;
with immediately placed and provisionalized implants has - pregnancy.
not yet been investigated. Hence the present randomized
controlled trial aims to assess the effect of connective
tissue grafting on the change in BBT in the aesthetic zone 2.3 Intervention
of single immediate implants.
One day pre-operatively antibiotic prophylaxis started
comprising of amoxicillin 500 mg, 3 t.i.d. for 7 days or clin-
2 MATERIAL AND METHODS damycin 300 mg, q.i.d. for 7 days in case of amoxicillin
allergy. Furthermore, twice daily the patients had to take
2.1 Study design a 0.2% chlorhexidine mouthwash for 7 days.
All surgical procedures were done by one oral and max-
Sixty patients were included in the randomized controlled illofacial surgeon (GMR). Local anaesthesia was applied
trial to assess the effect of connective tissue grafting before a flapless tooth extraction. Next, as defined by the
ZUIDERVELD et al. 3

manufacturer, implant site preparation was done on the sured BBT on Tpre, T1 (1 month after placement of the final
palatal side of the extraction socket using a surgical guide implant crown) and T2 (12 months after placement of the
to secure the proposed implant crown position. Augmenta- final implant crown) CBCT scans# using a designated pro-
tion of the buccal implant-socket gap was carried out with gram‖ . The CBCT scanner was validated for measuring
autogenous bone from the tuberosity or bone chips col- bone thickness25 with a method error of 0.05 mm (95%CI

100 × 100 mm were used for all CBCTs. CBCT’s were made
lected from the implant drills, and anorganic bovine bone* . 0.03 to 0.07). A standard voxel size of 0.30 and a FoV of
Next, the implant† was inserted 3 mm apical of the most
apical part of the prospective implant crown margin and according the manufacturer’s instructions with head and
primary stability was achieved with an insertion torque chin support, and alignment lights.
of ≥45Ncm. At this time point, the buccal wall, consisting First, the CBCT Digital Imaging and Communications
of the original buccal bone wall and the newly augmented in Medicine (DICOM) files from T1 and T2 were imported
mixture of autologous bone and anorganic bovine bone in into a medical image computing program** . Second, the
the socket gap, was at least 2 mm at every position at the exact position of the implant was then determined with
buccal side of the implant. Afterwards, a non-occluding Multimodality Image Registration using Information
screw-retained provisional restoration was designed by Theory (MIRIT; Figure 1)26 and a Maxilim file with the
taking an implant-level impression and a healing abut- exact coordinates of the implant in the particular patient
ment was placed. The moist environment of physiologic was created. Third, the planning software used these
saline solution and blood in which the particles are embed- coordinates to align a planning implant onto the exact
ded prevents particles getting stuck in impression material. same position. Fourth, measurements of the buccal bone
The test group received a CTG taken from the maxillary (in mm) could be done. The area of interest was the upper
tuberosity region, which was placed in a supraperiosteal 5 mm section of the implant starting at the implant neck
envelope flap prepared at the buccal aspect and secured‡ . towards the apical point (location M0 -M5 , Figure 2). The
The size of the graft was more or less standardized, being distance of the buccal bone outline to the center of the
≈8 mm in length, 6 mm in width and a thickness of implant was measured for each location. The radius of
1.5 mm. In cases with a small bony defect of the buccal the interior contour of the implant, as provided by the
wall, not only the periosteum of the original bony layer manufacturer for each location, was then subtracted from
was covered but also the added augmentation mixture of this measurement to determine the distance of the outline
autologous bone and anorganic bovine bone. The wounds of the implant to the buccal bone outline. This measuring
in both groups were closed with nylon sutures§ . The method prevented measurements at the interface between
screw-retained provisional restoration was placed, with a implant and bone that are disturbed by scattering. The
torque of 20Ncm, on the same day as implant placement. method applied results in measurements made at the
To fabricate the final implant crown with an individ- most outer buccal contour of the implant relative to the
ualized zirconia abutment¶ a definitive implant-level dental arch. This means that at this sagittal plane the BBT
open-tray impression was produced 3 months later. The is probably the thinnest and therefore the most predictive
abutment screw was torqued with 35Ncm. Depend- for the state of available buccal bone.
ing on the location of the screw access hole, the final Fifth, the DICOM files of the T1 and Tpre buccal bone
crown was either screw-retained or cement-retained. measurements were both imported into Maxilim and
All prosthetic procedures were accomplished by two aligned (Figure 3). Sixth, the Maxilim file with the exact
experienced prosthodontists (HJAM, CS), and all crowns coordinates of the implant from the CBCT image taken
were fabricated by one dental technician (MvdV). at T1 was inserted into a new DICOM file consisting of
the combined Tpre and T1 DICOM files to enable plac-
ing a planning implant according to the coordinates (Fig-
2.4 Measurement of buccal bone ure 3). Buccal bone measurements could now be done for
thickness the prospective implant position on the Tpre CBCT image.
It must be realized that the measurement for BBT at Tpre is
Slagter et al.24 showed that BBT changes can be measured actually the distance between a virtual implant and outer
in a reliable and reproducible way on cone beam com- contour of the buccal bone plate. This distance may cross
puted tomography (CBCT) images. Accordingly, we mea- the tooth root.

* Geistlich Bio-Oss, Geistlich Pharma AG, Wolhusen, Switzerland

† NobelActive, Nobel Biocare AB, Gothenburg, Sweden # iCAT 3D exam scanner, KaVo Dental GmbH, Biberach, Germany
‡ 4-0 vicryl, Johnson&Johnson Gateway, Piscataway, NJ. ‖ NobelClinician, version 2.1, Nobel Biocare-Guided Surgery Center,
§ Ethilon, Ethicon, Johnson & Johnson, Amersfoort, The Netherlands Mechelen, Belgium
¶ NobelProcera, Nobel Biocare AB, Gothenburg, Sweden ** Maxilim, version 2.3, Medicim, Sint-Niklaas, Belgium
4 ZUIDERVELD et al.

FIGURE 1 The planning implant is aligned with the implant in the CBCT image using MIRIT to obtain the exact coordinates for the
procedure

cally designed software was applied for full-screen analysis

of the radiographs.18 Bone exceeding the implant platform
was scored as no bone loss. Change in marginal bone level
at the mesial and distal side of the implant was averaged.

2.6 Measurement of mid-buccal mucosa

level

The change in MBML was assessed at T2 and compared

with the pre-operative MBML (Tpre ) according to mea-
surements from standardized intra-oral photographs.*27
The photographs were calibrated by a periodontal probe
held close to and parallel to the long axis of the tooth
adjacent to the implant. The photographs were analysed
using a digital picture editing program.† Measurements
F I G U R E 2 The planning implant is superimposed precisely were done between the reference line though the incisal
over the implant in the CBCT image according to the previously edges of the natural adjacent teeth and the mucosal mar-
obtained coordinates. Each millimeter measurement (M0-M5) is gin of the non-restorable teeth.18 There was no method
marked along 5 mm of the axis of the implant, starting at the neck applied to compensate for possible wear of the incisal edge
of the implant of the neighboring teeth nor possible ongoing skeletal
growth. MBML as well as volumetric changes in the tissue
buccal from the implant have been reported before.18,19
All measurements were carried out by three operators The present study only used the MBML data from those
(H.J.A.M., G.C.B., E.G.Z.) blinded for the specific groups patients who had CBCT scans available for BBT measure-
and in a random order. Because inter-examiner reliability ment from the pre-operative situation and 12 months after
and intra-examiner reliability of the method was analyzed placement of the final implant crown.
in an earlier manuscript, with partly the same examiners,
and with a favorable outcome, it was decided not to explore
these reliabilities again.21 2.7 Assessment of gingival phenotype

The gingival phenotype (thin/thick) was assessed at Tpre

2.5 Measurement of approximal by means of periodontal probe transparency through the
marginal bone level gingival margin.28

Intraoral radiographs for analysis of approximal marginal

bone level were made with an individualized lab-made * Canon EOS 650D, Canon Inc., Tokyo, Japan
acrylic splint for standardization27 at T1 and T2 . Specifi- † Adobe Photoshop CS5.1, Adobe Systems Inc., San Jose, CA
ZUIDERVELD et al. 5

F I G U R E 3 Alignment of CBCT image DICOM files from Tpre and T1 and alignment of the planning implant according to the coordinates
of the prospective position of the implant in the CBCT image taken at Tpre , with the failing tooth still in place

3 STATISTICAL ANALYSIS TA B L E 1 Patient characteristics per study group at Tpre

(n = 28) (n = 27)
Test group Control group
The original sample size calculation was based on change Variable
in MBML as primary outcome, as shown in the manuscript Male/Female 12/16 12/15
by Zuiderveld et al.18 At least 27 patients per group (sig- Age (years) mean ± 45.3 ± 15.3 (19-68) 47.2 ± 16.5 (21-82)
nificance level of 5%, power of 80%) had to be included SD (range)
and to compensate for withdrawals, 30 patients per group Gingival phenotype 18/10 13/14
were included. The sample size calculation for the present Thin/Thick
study was done post factum and was done using an online Implant site location 16/9/1/2 11/8/7/1
sample size calculator* according to an estimated change I1 /I2 /C/P1
4.6 ± 0.68 4.2 ± 0.88
after implant placement of 0.4 mm (SD = 0.7) for the test
of the buccal bone between pre-extraction and 1 year Pre-operative bone

group and of 0.5 mm (SD = 0.6) for the control group.26 mean ± SD
defect (mm)

A minimum of 55 patients in total is needed (significance Implant length 5/23 7/20

level of 5%, power of 80%). For this study, we had to 15/18 mm
exclude patients, but still have the required minimum Implant diameter 11/17 12/15
number of patients needed for the analysis. 3.5/4.3 mm
The normal distribution of the continuous data was Abbrevation: Tpre , pre-operative state.

Q-plots. The normal distributed data, shown by means ±

assessed by Shapiro-Wilk tests together with normal Q-

standard deviation (SD), were analysed using ANCOVA to addition, one patient from the test group and two patients
detect differences between groups and to test the effect from the control group had to be excluded from the final
of gingival phenotype on BBT and the effect of the pre- analysis because of unclear landmarks caused by scatter
operative bone defect on BBT. The correlations between artefacts in the CBCT.
MBML and BBT, marginal bone level and BBT (locations During follow-up, no signs of soft tissue complications
M0-M5 combined) were tested by a Pearson’s test. at the donor site, or extensive bleeding of or perforation
through the maxillary sinuses after harvesting bone from
the tuberosity region, were observed. Additionally, there
4 RESULTS were no objective signs of infection.

The patient characteristics of the study groups at Tpre are

depicted in Table 1. There was not a significant difference 4.1 Buccal bone thickness

The average BBT at Tpre was 2.38 ± 0.81 mm and 2.28 ±

in patient characteristics between the test and control
group. Of the original 60 patients, 55 patients had CBCT
data available, from before and 1 year after implant place- 0.92 mm for the test and control group, respectively. At

1.62 ± 0.74 mm and 2.00 ± 0.90 mm respectively. At T2 ,

ment, for the current analysis (Figure 4). One implant was T1 , the BBT in the test and control groups was on average

the average BBT was 1.57 ± 0.80 mm in the test group and
lost in both groups because of failing osseointegration. In

* Sample Size Calculator, DSS Research, SPH Analytics, Alpharetta, GA 1.83 ± 0.94 mm in the control group.
6 ZUIDERVELD et al.

FIGURE 4 CONSORT flow diagram

TA B L E 2 Change in buccal bone thickness between Tpre— T2 4.2 Change in approximal marginal
bone level
(n = 28) (n = 27)
Test group Control group

Mean ± SD Mean ± SD
0.05 ± 0.33 mm and 0.01 ± 0.38 mm in the test and con-
Between T1 and T2 , the average loss of marginal bone was
Location (mm) (mm) P
-1.21 ± 1.07 -0.91 ± 0.77
between the groups (P = 0.95).
M0 0.23
-0.80 ± 0.86 -0.42 ± 0.57
trol group, respectively, without a significant difference
M1 0.06
M2 -0.81 ± 0.77 -0.37 ± 0.62 0.02
M3 -0.72 ± 0.63 -0.31 ± 0.63 0.02
M4 -0.69 ± 0.59 -0.35 ± 0.69 0.05 4.3 Change in mid-buccal mucosal level
-0.65 ± 0.63 -0.37 ± 0.63
A MBML gain of 0.07 ± 0.85 mm (95%CI −0.25 to 0.40) was
M5 0.11
Total -0.84 ± 0.61 -0.46 ± 0.54 0.02*

the control group (P = 0.03) had a loss of −0.52 ± 1.16 mm

observed at T2 compared to Tpre in the test group, whereas

(95%CI −0.98 to −0.07).

Abbreviations: Tpre , pre-operative state; T2 , twelve months following place-
ment of the final implant crown.
*Significant difference between study and control group.

4.4 Effect of gingival phenotype on BBT

test group and control group was −0.84 ± 0.61 mm and
The average change in BBT between Tpre and T2 for the

−0.46 ± 0.54 mm, respectively (P = 0.02). The change A thin or thick pre-operative gingival phenotype showed

and T2 (P = 0.04). In a regression model it was shown

in BBT at the M0-M5 locations between Tpre and T2 is a significant effect on the change in BBT between Tpre
displayed in Table 2.
ZUIDERVELD et al. 7

that both gingival phenotype (P = 0.04) and use of a CTG

(P = 0.006) significantly affected the change in BBT.
Because most teeth in the anterior maxilla display a thin
(≤1 mm) buccal bone wall,31–33 the BBT measured at T2 and
the amount of loss of BBT observed between Tpre -T2 could
suggest that the entire buccal bone wall was lost as a con-
4.5 Effect of pre-operative bone defect sequence of the bone remodeling process following tooth
on BBT and MBML extraction, as proposed earlier.34,35 However, according to
the reported data on the average BBT 1 year after place-
The pre-operative bone defect in the test group showed no ment of the final implant crown, it can be suggested that

Tpre and T2 (r = 0.08; P = 0.69) and with the change in

significant correlation with the change in BBT between using the grafting procedure with an implant-socket gap of

MBML between Tpre and T2 (r = −0.28; P = 0.15). And

at least 2 mm 6,12 results in a new buccal bone wall with suf-
ficient width. This suggestion is supported by the results
also in the control group the pre-operative bone defect of a recent cohort-study, which showed that a new buccal

between Tpre and T2 (r = −0.29; P = 0.14) and with the

showed no significant correlation with the change in BBT bone wall can be created when grafting the implant-socket

change in MBML between Tpre and T2 (r = 0.21; P = 0.29).

gap buccal of the immediately placed implant. This wall
buccal of the implant was well preserved for at least 1 year
after immediate implant placement.29 The created buccal
bone wall even had a sufficient width in the test group,
4.6 Correlation testing between MBML which showed more pronounced bone resorption than in
and BBT the control group, to support the overlying peri-implant
soft tissues and to preserve the mid-buccal mucosal level.

changes in MBML and BBT (r = −0.22 and P = 0.26 for

No significant correlations were found between the The greater decrease in BBT in the test group was not

the test group and r = −0.09 and P = 0.67 for the control
accompanied with a greater recession of the MBML when
applying a CTG. This may suggest that connective tissue
group, respectively). grafting can limit the amount of recession of the MBML, as
already shown by the study of Zuiderveld et al.,18 resulting
in a beneficial effect for the aesthetic outcome. However,
4.7 Correlation testing between this beneficial effect could not be confirmed by a better
approximal marginal bone level and BBT Pink Esthetic Score (PES)36 for the test group compared
to the control group. It has to be mentioned that in both

in marginal bone level and BBT for the test group (r = 0.14
No significant correlations was found between the changes groups a high acceptable level of PES ≥6 was attained.18

and P = 0.49); there was a significant correlation between

A possible explanation for a better preservation of the
MBML when applying a CTG could be thickening of the

group (r = 0.46 and P = 0.015).

the changes in marginal bone level and BBT for the control mid-buccal mucosa, as proposed earlier.14,15 However,
the study by van Nimwegen et al.19 on the same study
group could not confirm that applying a CTG results in
a thickened mid-buccal mucosa, because a general loss
5 DISCUSSION of the mid-buccal mucosal volume was found. Another
possible explanation for the better MBML in the test group
The results of the present study reveal that placement of a could be that the CTG might not have been placed in
CTG, compared to no soft tissue graft, in a single immedi- its entirety into the prepared envelope, causing a small
ate implant site results in a greater decrease in BBT after 1 amount of the graft to be located coronal of the mucosal
year. margin resulting in the graft adding to the mucosal level.
Significantly more buccal bone loss was noted in the The short-term results of this study show that connec-
group that received a CTG (test group). A possible expla- tive tissue grafting results in significantly more buccal
nation for the higher loss of BBT in the test group could bone loss, although the MBML is preserved better than
be the surgical intervention used for the application of the when no CTG is applied. Therefore, based on these results,
CTG. A small envelope flap was prepared at the mid-buccal the clinical recommendation is that a CTG should only
aspect, which disrupted the vascularization between the be considered concomitant with immediate implant
mucosa and periosteum. The disruption in the blood sup- placement in order to prevent asymmetry in facial mucosa
ply, together with the bone remodeling process after tooth levels between the peri-implant mucosa and the gingival
extraction,7,8 could have induced further loss of mid- contour of the neighboring teeth.
buccal bone.29,30 Moreover, adding a CTG seems to have An important limitation of this study is that long-term
a larger effect on loss of BBT than the gingival phenotype. results are not yet available. Such data could show whether
8 ZUIDERVELD et al.

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CONFLICT OF INTEREST
Implants Res. 2017;28:902-910.
All authors report no conflict of interest. This study was
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