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Soft Tissue Grafting Around Teeth and Implants

Article  in  Oral and maxillofacial surgery clinics of North America · August 2015

DOI: 10.1016/j.coms.2015.04.010 · Source: PubMed

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S o f t T i s s u e Gr a f t i n g
A ro u n d Te e t h a n d
I mplants
George R. Deeb, DDS, MDa,*, Janina Golob Deeb, DDS, MSb

KEYWORDS
 Free gingival graft  Subepithelial connective tissue graft  Recession  Soft tissue defect  Allograft
 Xenograft

KEY POINTS
 Esthetic appearance and functional longevity for teeth and implants often requires conversion of
unfavorable soft tissue traits to more favorable ones.
 Improvement of tissue quality and quantity can be accomplished with many different techniques
and materials, and largely depends on clinical presentation of the case and the familiarity of the
clinician with the procedures and materials available.
 Identification of causal factors, selection of appropriate surgical technique, and evidence-based
material selection lead to predictable success when improving soft tissue characteristics around
teeth or implants.

THE IDEAL CHARACTERISTICS OF THE SOFT optimal soft and hard tissue health.3 However, in
TISSUE TOOTH/IMPLANT INTERFACE patients maintaining proper plaque control, the
absence of attached gingiva around teeth does
The presence of healthy attached tissue at the not result in an increased incidence of soft tissue
tooth and implant soft tissue interface correlates recession.1,4 It has been shown in long-term
with long-term success and stability in function studies that even minimal amounts of keratinized
and esthetics. Not only can a lack of keratinized tissue can provide long-term stability of soft tissue
tissue facilitate plaque aggregation around teeth margin in the presence of good plaque control.1
and implants but it can also lead to recession of Early studies suggested that the recession of
free soft tissue margin in the esthetic zone. The soft tissue margin around implants may be the
thicker periodontium is less prone to recession, result of the remodeling of the periimplant soft tis-
because of the thickness of the cortical bone as sue barrier. Lack of masticatory mucosa and the
well as the thickness of the surrounding gingiva. mobility of periimplant soft tissue were related to
Treatment of mucogingival deficiencies has more pronounced soft tissue recession around im-
become a large part of practices involving teeth plants.5 Plaque-induced inflammation has been
and implants. The ramifications of not having an shown to cause recession when mucosal margins,
adequate keratinized tissue surrounding teeth rather than gingiva, are surrounding implants.6
have been studied extensively for decades,1,2 Thicker keratinized tissue facilitates plaque
oralmaxsurgery.theclinics.com

and have also extended into implantology. The removal around implants. Plaque has been found
presence of gingiva is strongly correlated with as the causal factor in periodontal diseases7 as

a
Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, 521
North 11th Street, Richmond, VA 23298, USA; b Departments of Periodontics and General Practice, School
of Dentistry, Virginia Commonwealth University, 521 North 11th Street, Richmond, VA 23298, USA
* Corresponding author.
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 27 (2015) 425–448

http://dx.doi.org/10.1016/j.coms.2015.04.010
1042-3699/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
426 Deeb & Deeb

well as periimplant inflammation, and its removal is When considering correction of recession it is
paramount in tooth and implant long-term health. important to identify the presence and the amount
Facilitating plaque removal is not the only indica- of gingiva as well as causal factors contributing to
tion when considering improvement of soft tissue displacement of soft tissue margin. Causal factors
structure surrounding teeth or implants. Esthetic of soft tissue recession around teeth include the
demands for implants have become as high as quantity and quality of surrounding keratinized
those for natural dentition. Exposed metal or any attached tissue, supporting alveolar bone, and
visible discrepancies in soft tissue volume or mar- the level of plaque control of the affected area.
gins suggesting an implant-supported prosthesis Causes of soft tissue defects surrounding implants
in anterior regions have become largely unaccept- include poor implant spatial positioning, incorrect
able by patients. Implant-supported restorations abutment contour, excessive implant diameter,
and teeth restored side by side should be in har- horizontal biologic width formation, and peri-
mony, not only when it comes to prosthetic supra- odontal phenotype.11
structures but also in levels of gingival margins,
thickness, color, and contour of adjacent gingiva. CLASSIFICATION OF RECESSION
Several soft tissue grafting procedures has been
developed to improve both the volume of kerati- Several classification systems have been devel-
nized tissue and the soft tissue contour around im- oped to assess and quantify the amount of sur-
plants. Concepts for these surgical techniques rounding soft tissue and osseous components.
have been drawn from procedures developed to Sullivan and Atkins12 introduced a classification
enhance soft tissue support around teeth. system in 1968 to describe recession around
teeth. This classification system was based on
DEVELOPMENT OF MUCOGINGIVAL the width and length of recession. It was already
DIAGNOSIS AND SURGERY established at that time that those parameters
determined the amount of root coverage obtain-
The term mucogingival surgery was first intro- able with soft tissue grafting procedures.
duced by Friedman8 in 1957 in reference to cor- Miller13 introduced his classification system in
recting relationships between mucosa and 1985 (Box 1). He related the extent of the soft tis-
gingiva around teeth. In the following decades, sue recession to the location of the mucogingival
that term has expanded to include numerous pro- junction as well as the height of interproximal clin-
cedures used to correct and alter defects, ical attachment adjacent to the surface affected by
position, thickness, and the width of keratinized the recession.
tissue surrounding teeth. As implantology has Miller’s13 classification is a helpful diagnostic
expanded and esthetic demand for prosthetic re- tool in treatment planning and setting realistic ex-
placements has grown, periodontal plastic surgery pectations for both patients and clinicians. Root
procedures have been developed around implants coverage can be predictably obtained in class I
and edentulous ridges restored with pontics and and II groups, only partially in class III, and not at
removable prostheses. The term periodontal plas- all in class IV. Properly diagnosing the soft tissue
tic surgery was introduced by Miller9 in 1988 and recession is helpful in choosing a proper soft tis-
presently includes procedures to prevent or cor- sue grafting technique and setting expectations
rect oral soft tissue defects of anatomic, develop- for surgical outcome.
mental, traumatic, and disease-related origin. In 1999, the International Workshop for Classifi-
cation of Periodontal Diseases and Conditions
GINGIVAL RECESSION AROUND TEETH AND formed by the American Academy of Periodontol-
IMPLANTS ogy agreed on a new classification system for peri-
odontal diseases. Category VIII on developmental
The displacement of the soft tissue margin in an or acquired deformities and conditions was added
apical direction from the cementoenamel junction to provide more comprehensive diagnostic tool for
leads to exposure of the root surface of a tooth, soft tissue characteristics around teeth and eden-
and is referred to as a marginal soft tissue reces- tulous ridges (Table 1).14
sion.10 When the soft tissue margin recedes
apically around an implant, it can lead to exposure ESTHETIC CONSIDERATIONS
of the abutment or implant body depending on the
extent of displacement, as well as the design of the Loss of gingival symmetry is most notable on ante-
implant and its suprastructure. In both cases, the rior teeth15 and implants, especially with regard to
term soft tissue margin is inclusive of either mu- the principles of gingival zenith positions and
cosa or gingiva, whichever is present at the site. levels.
 Soft Tissue Grafting Around Teeth and Implants 427

Box 1 points should be used as guides to reestablish

Miller classification system of marginal soft the proper intratooth gingival zenith line of the
tissue recession maxillary anterior teeth during root coverage and
reconstructive procedures.16
Class I:
 Recession does not extend to mucogingival
junction THICK VERSUS THIN GINGIVAL
ARCHITECTURE
 There is no loss of interproximal clinical
attachment Treatment planning for dental implant placement
Class II: should consist of assessment of the periodontal
biotype of both the proposed implant site and
 Recession extends to or beyond mucogingival the adjacent dentition. This soft tissue assessment
junction
is particularly important for the immediate implant
 There is no loss of interproximal clinical case as well as treatment in the esthetic zone
attachment (Fig. 1).
Class III: The thick, flat periodontal biotype is character-
ized by dense fibrotic gingiva. There is a larger
 Recession extends to or beyond mucogingival
junction
zone of attached gingiva, with smaller embrasures
associated with square-shaped teeth. Gingival
 Some interproximal clinical attachment loss is scallop on anterior teeth is flat and does not
present or malpositioning of teeth is present
exceed 3 to 4 mm. The contact points are long
Class IV: and are located in the middle third of the teeth.
 Recession extends to or beyond mucogingival Soft tissue is supported by thick bone, with the
junction high incidence of exostosis resisting the tendency
for recession to occur.
 Severe interproximal clinical attachment loss
The thin periodontal biotype displays a thin,
is present or severe malpositioning of teeth
is present scalloped gingiva with a narrow zone of attach-
ment. The teeth are triangular and have long inter-
From Miller PD. A classification of marginal tissue proximal contacts in the incisal third region.
recession. Int J Periodontics Restorative Dent 1985;5:9.
Gingival scallop on anterior teeth can reach 4 to
6 mm. The thin periodontium often reveals undu-
lating contours of the prominent roots of the teeth
Tarnow showed that the gingival zenith line of alternating with the concave interdental bone. In
the lateral incisors relative to the adjacent central this biotype, bone is thin and has a high incidence
incisor and canine teeth is positioned more coro- of dehiscence and fenestration defects. Brushing
nally by approximately 1 mm. These reference can result in soft tissue recession over the

Table 1
Developmental or acquired deformities and conditions

Mucogingival Deformities and Conditions Around Mucogingival Deformities and Conditions on

Teeth Edentulous Ridges
1. Gingival/soft tissue recession 1. Vertical and/or horizontal ridge deficiency
a. Facial or lingual surfaces
b. Interproximal (papillary)
2. Lack of keratinized gingiva 2. Lack of gingiva/keratinized tissue
3. Decreased vestibular depth 3. Gingival/soft tissue enlargement
4. Aberrant frenum/muscle position 4. Aberrant frenum/muscle position
5. Gingival excess 5. Decreased vestibular depth
a. Pseudopocket
b. Inconsistent gingival margin
c. Excessive gingival display
d. Gingival enlargement
6. Abnormal color 6. Abnormal color
From Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol
1999;4(1):1–6.
428 Deeb & Deeb

Fig. 1. (A) Thick, flat periodontal biotype is characterized by dense fibrotic gingiva, large zone of attached
gingiva, smaller embrasures, and square-shaped teeth. (B) Thin periodontal biotype has a thin, scalloped gingiva
with a narrow zone of attachment. The teeth are triangular, and the thin periodontium often reveals undulating
contours of the prominent roots of the teeth and bone.

dehiscence defects, which continues until the Kan and colleagues17 recommend that the
bone margin is reached. placement be 1 mm palatal in relation to the facial
Kan and colleagues17 evaluated the dimensions emergence profiles of the adjacent teeth, and not
of the periimplant mucosa around 2-stage maxil- less than 1 mm because of the risk of losing the
lary anterior single implants. The investigators facial bone and soft tissue.
concluded that the level of the interproximal
papilla around the implant is independent of the The Implant Should Be Placed with the
proximal bone level next to the implant, but is Platform at the Level of the Gingival Zenith
related to the interproximal bone level next to the and 3 mm Apical to the Soft Tissue Margin
adjacent tooth. Greater periimplant mucosal di-
Gingival zenith position (GZP) does not line up with
mensions were noted in the presence of a thick
the middle of the facial surface of the tooth or ver-
periimplant biotype compared with a thin biotype.
tical bisected midline (VBM) for all anterior tooth
groups. The largest discrepancy between GZP
THE RELATIONSHIP BETWEEN IMPLANT
and VBM was noted in maxillary central incisors
PLACEMENT AND SOFT TISSUE
with GZP located 1 mm distal to the VBM.16 The
The relationship between the bone and soft tissue lateral incisors showed an average of 0.4 mm
ultimately defines the final esthetic result. The discrepancy, whereas the canines showed almost
three-dimensional relationship between the no deviations of the GZP from the VBM.16
implant and surrounding bone determines the
soft tissue contours and interdental papilla. Implants Should Be Placed with a Minimum of
1.5 mm Between the Adjacent Tooth and
Implants Should Be Placed 3 mm Below the Implant
Facial Gingival Margin in an Apicocoronal
Esposito and colleagues19 indicated a strong cor-
Dimension for the Following Reasons
relation between bone loss of adjacent teeth and
 To allow for prosthetic abutment placement horizontal distance of the implant fixture to the
and formation of biologic width. tooth. The greatest amount of bone loss was noted
 To allow for creation of a natural emergence at the lateral incisor position.
profile.
 To allow for restorative margins to be placed Implants Should Be Placed with an
subgingivally. Interimplant Distance of at Least 3 mm in a
 To allow for age-related recession without im- 2-Stage Protocol
mediate exposure of the implant abutment Tarnow and colleagues20 in their retrospective
interface. study of patients with 2 adjacent implants found
that when implants were placed within 3 mm of
Implants Should Be Placed in a Buccolingual
each other they developed 1.04 mm of interprox-
Dimension 1 to 2 mm Palatal from the
imal bone loss compared with implants placed
Anticipated Facial Margin of the Restoration
with greater than 3.0 mm of bone between them,
Schneider and colleagues18 recommend a 2-mm which lost only 0.45 mm of bone. The loss of height
palatal placement in anticipation of a 1.4-mm of interproximal bone has an effect on papilla
lateral bone loss as a guideline. support.
 Soft Tissue Grafting Around Teeth and Implants 429

PAPILLA tooth or another implant. Tarnow and colleagues26

observed that, when placing 2 implants adjacent
Maintaining papillae between anterior teeth leads to each other, only an average of 3.4 mm of soft
to optimal gingival contour and appearance. Sur- tissue height can be expected to form over the in-
gical techniques for soft tissue grafting around terimplant crest of bone.
teeth all include papilla preservation in height Schropp and Isidor27 evaluated soft tissue levels
and at least partial thickness. and papilla dimensions for early versus delayed
single implants. Implants placed 10 days following
Papilla Adjacent to Teeth
extraction tended to be superior to delayed im-
Maintenance of interproximal papillae is more pre- plants regarding soft tissue appearance at crown
dictable in periodontally healthy patients because delivery as well as 10 years later. The implant re-
of predictable tissue rebound over time, which gion does not seem to influence the papilla,
can be anticipated by the height of interproximal although patients younger than 50 years received
bone on the adjacent teeth.21 Complete papilla fill significantly better papilla scores. An apically
has been observed when the distance from the located bone level at the tooth neighboring the
contact point to the bone crest was 5 mm or less. implant negatively influenced the papilla dimen-
When the distance exceeds 6 mm, papillae are pre- sion. In contrast, the presence of a bone defect
sent only 56% of time.22 Restorative solutions for buccally to the implant at second-stage surgery
manipulation of contact point location are used to did not have a negative impact on the gingival
reduce the distance from contact point to the crest margin 10 years after implant placement.27
as well as adding the length to the contact surface
and bulk to coronal contours. Surgical techniques Provisional Restoration
intended to increase the volume of papillae include
The selection of the provisional restoration signifi-
case reports of the use of platelet-rich fibrin,23 in-
cantly influences healing of the soft tissues (Fig. 2).
jection of hyaluronic acid–based gel,24 and con-
Placement of an immediate provisional affects the
nective tissue graft with coronally advanced flap
periimplant tissue morphology according to its
(CAF).25 Most case reports on these techniques
emergence profile.28 Papilla preservation as well
represent a small number of cases and short-term
as restoration can be accomplished. Part of the
follow-up, failing to show long-term stability.
anterior esthetic case planning should involve
planning for the provisional restoration. In general,
Papillae Adjacent to Implants
fixed provisionals work better than removable pro-
The projected height of a papilla next to an implant visionals. Screw-retained provisional restorations
largely depends on whether it is adjacent to the are preferred in cases in which soft tissue contours

Fig. 2. (A) Preoperative view of a #9 edentulous ridge planned for a single-tooth implant. (B) Surgical guide in
place during implant placement. Note that the guide pin is palatal in order maintain the buccal plate and prevent
recession of the soft tissue. (C) Intraoperative view with a 3.0-mm healing abutment in place. The 3.0-mm healing
abutment is flush with the gingiva and ensures that proper emergence can be achieved. (D) Screw-retained pro-
visional with the correct gingival contours. (E) The provisional restoration in place along with the veneer showing
acceptable esthetic outcome. (F) Postoperative panoramic film showing the implant and provisional crown in
place.
430 Deeb & Deeb

are critical. Screw-retained restorations avoid When performing the socket preservation proce-
cement-caused periimplant inflammation. Screw- dure, anatomic features of the socket which will
retained restorations also allow retrieval and become a future implant site should be assessed
adjustment of the contours of the restoration, and improved with grafting techniques. Closure af-
which are critical in guiding papilla restoration. ter extraction can be manipulated in ways to create
Contact points on adjacent teeth as well as emer- or move keratinized tissue for future implant place-
gence dictate the final result. ment. Covering bone graft with a membrane or soft
tissue graft results in expansion of gingival tissue.
Obtaining primary closure by advancing the flap
SOFT TISSUE MANAGEMENT BEFORE
often comes at the expense of displacing or losing
IMPLANT PLACEMENT
facial keratinized tissue.
Extraction Sockets
Patient factors that define the success of an
In the absence of keratinized tissue or when implant placement include bone level, buccal
gingiva is present but inflamed and fragile, it is bone thickness, soft and hard tissue relationship,
important to incorporate procedures to preserve and gingival biotype.29
and augment surrounding connective tissue in Bone grafting for socket preservation or ridge
early phases of treatment (Fig. 3A–H). Following augmentation techniques can be implemented to
extraction in an anterior segment with deficient improve osseous characteristics of the site. The
gingiva, the clinician might choose not to proceed bone support will define the soft tissue architec-
with an immediate implant placement but rather ture after healing. Connective tissue grafts or
resort to a staged approach. pedicle grafts can be used to augment deficient

Fig. 3. (A) Preoperative view of a patient with a thin, scalloped periodontium with external resorption of tooth
#9. (B) Extracted tooth with external resorption visible on the buccal aspect of the tooth. (C) Postextraction view
showing buccal wall defect. (D) Rigid collagen membrane bridging the buccal wall dehiscence before placement
of bone graft into the socket. The connective tissue graft for socket coverage has been harvested. (E) Connective
tissue graft sutured into place over the socket preservation procedure. (F) Natural tooth bonded into place post-
operatively and without contacting the ridge. (G) One-week postoperative view showing improved bulk and co-
lor after socket preservation procedure. (H) Four-month postoperative result.
 Soft Tissue Grafting Around Teeth and Implants 431

soft tissue components. Autogenous grafts can be of greater prosthesis retention during the healing
allowed to heal in part by secondary intention stage (Fig. 4).
further enhancing the amount of keratinized tissue
available for future implant placement. Treatment Planning for Soft Tissue Grafting
Note that immediate implant placement into Around Teeth and Implants
sockets with deficient facial keratinized tissue
The ultimate goal of soft tissue grafting is to
and thin buccal bone may lead to unpredictable
improve the prognosis of affected teeth or im-
height and contour of soft tissue margin and
plants. Prognosis depends on the ability to
esthetic outcome. Delaying implant placement
practice good plaque control and to maintain
and creating healthy and adequate amounts of
healthy soft tissue margins. In esthetic areas,
gingiva first yields more predictable esthetic
achieving optimal soft tissue contours around
results.
teeth, implants, or prostheses is also of great
importance.
SOFT TISSUE MANAGEMENT AT THE TIME OF Numerous techniques involving soft tissue
IMPLANT PLACEMENT manipulation from adjacent or distant donor sites
have been developed to cover exposed roots and
Sites augmented with subepithelial connective tis-
enhance soft tissue structure in areas with deficient
sue grafts (SCTG) at the time of implant placement
or absent gingiva. Conventional periodontal plastic
have better esthetics and thicker periimplant tis-
surgical techniques are generally separated into
sues.30 When SCTG is used with immediate
pedicle grafts and free soft tissue grafts (Box 2).
implant placement and provisionalization in the
esthetic zone it significantly improves mainte-
nance of facial gingival level.31 FREE SOFT TISSUE GRAFTING
Grunder32 measured the dimension of the labial When treatment planning a soft tissue graft it is
volume before and 6 months after implant place- important to consider the goal. Indications can
ment in the maxillary anterior area with or without be driven by esthetic demands with the purpose
SCTG using a flapless tunnel technique. The non- of establishing a harmony with regard to health,
grafted group had an average 1.063-mm loss of height, volume, color, and contours of gingiva
volume, whereas the grafted group presented with the surrounding dentition.
with a slight gain of 0.34 mm. These results In addition, indications are often related to
confirmed the effectiveness of placing a soft tissue inability to remove plaque efficiently around teeth
graft at the time of immediate implant placement in and implants surrounded by thin mucosa, resulting
the esthetic zone.32 in recession. Longitudinal evaluations conclude
In totally edentulous patient, firm keratinized tis- that minimizing inflammation is sufficient and is
sue surrounding the implants and adequate necessary to maintain attachment levels despite
vestibular depth are among the determining fac- the width of keratinized tissue surrounding teeth.34
tors for long-term implant success. In the staged Therefore it is important to educate patients about
approach of mandibular implant reconstruction, how to properly exercise oral hygiene and to
adequate vestibular depth and gingiva surround- consider soft tissue surgery in appropriate circum-
ing the implants can be readily established at the stances when enhanced soft tissue will result in an
time of implant placement or when the implants improved prognosis of the grafted tooth or
are uncovered. implant.
However, in cases in which extractions and In cases in which the sole goal is to increase the
alveolar ridge reduction are done in the mandible amount of keratinized tissue, the most suitable
immediately before implant placement, surgeons technique remains a free gingival graft. When the
have a challenging task to maintain adequate ker- desired outcome includes coverage of exposed
atinized tissue and vestibular depth on buccal and root, connective tissue grafting provides more pre-
lingual aspects of the implants. Securing both dictable outcomes.35
flaps apically to a fixed and stable bony anchorage
greatly reduces the likelihood of prolapse of the THE FREE GINGIVAL GRAFT
buccal vestibule and elevation of the lingual floor
into prosthetic space as well as beyond the The term free gingival graft was introduced in 1966
implant margins. This fixed anchorage is by Nabers36 and this graft is now referred to as free
especially important in patients who cannot wear epithelialized soft tissue graft. This technique orig-
prosthetic devices during the healing phase.33 inally used tissue removed after gingivectomy, but
Single-stage surgery with the placement of healing was later modified to include palatal or mastica-
abutments allows the patient the additional benefit tory gingiva as a primary donor source.37
432 Deeb & Deeb

Fig. 4. (A) Five lower implants placed for an immediate loaded full-arch provisional restoration. (B) Close-up view of a
fissure burr being used to make an interimplant osteotomy of the lingual cortical bone as a means of stabilizing flaps in
an apical position. In this example the lingual cortex is being perforated because of the wide buccolingual dimension
of the alveolar ridge as well as to avoid inadvertent damage to the implants. (C) Intraoperative view showing the su-
turing sequence. The operator passes from the buccal tissues through the alveolus and through the lingual tissues
before tying the knot over the ridge to secure the tissues. (D) Intraoperative view with 3 transalveolar sutures in place.
The sutures are placed in the interimplant bone and secured. The rest of the final closure is completed in chromic gut
suture. Note the preservation of keratinized tissue and apical position of the flaps. (E) Intraoperative view after implan-
tation showing the needle being passed through the alveolus in order to show the placement of the transalveolar os-
teotomy in a 5-mm apical position. For altering vestibular height the osteotomy should be placed apically, as shown.
For use the buccal flap should be engaged before entering the osteotomy and the lingual flap on exiting, as in Fig. 3. (F)
Immediate postoperative view of the closure using the transalveolar suture (arrow) securing the flaps in an apical po-
sition in order to increase vestibular depth. (G) One week after surgery showing favorable healing and stable tissue
adaptation around the implants. The transalveolar sutures (arrows) are still intact.

The autogenous free gingival graft can be subdi- it is not suited when root coverage is attempted.
vided by thickness of the donor tissue into 3 The thin free gingival graft heals the fastest but
categories: also has the highest percentage of secondary
shrinkage after healing (25%–30%).38,39 The donor
1. Thin (0.5–0.8 mm)
site is shallow and therefore heals mostly
2. Average (0.9–1.4 mm)
uneventfully.
3. Thick (1.5 to >2 mm)
The average-thickness graft is best suited for all
The thin graft is well suited to increasing the types of grafting except root coverage. This graft
amount of keratinized gingiva and provides the provides acceptable appearance and better pro-
best color match. A thin graft has to be placed in tection against future recession than the thin graft.
intimate contact with an intact blood supply of The donor site is deeper, which can cause more
the recipient site with the incision on the recipient complications following surgery. A palatal stent is
site placed submarginally. Placement over an recommended to protect the donor site and
exposed root surface should be avoided because ensure blood clot stabilization.
 Soft Tissue Grafting Around Teeth and Implants 433

Box 2 of color and thickness incompatibility with adja-

Conventional periodontal plastic surgical cent gingiva (Fig. 5).
techniques
Indications for Free Gingival Graft
Pedicle graft
Free gingival grafts remain the gold standard for
Flap advancement procedures: augmentation of width and thickness of keratinized
 Coronally positioned flaps tissue around teeth and implants. It has remained a
predictable technique when objectives include:
 Semilunar coronally positioned flaps
Flap rotation procedures:  Augmentation of gingival dimensions
 Elimination of the frenum
 Laterally sliding flap
 Increase of vestibular depth
 Partial-thickness double pedicle graft  Improvement of local anatomic factors asso-
 Rotational flap ciated with facial tooth position
 Transpositioned flap  Large, prominent roots with dehiscence
 Stabilization of progressive gingival recession
Free soft tissue grafts  Correction of ridge deformities and undercuts
 Free gingival grafts  Protection of denture bearing surface42
 SCTGs Free gingival grafting can be used as a 2-stage
Free soft tissue grafts can be further divided de- procedure for root coverage with coronal
pending on the source of origin into: advancement once the graft has healed. It has
 Autogenous grafts also been found to achieve root coverage as a
1-step surgical procedure in 44%43,44 and up to
 Allografts 89.9% of the sites when applied appropriately.40
 Xenografts Despite its ability to obtain root coverage, free
gingival graft is not suitable for areas with esthetic
concerns. Previous studies have shown that free
The thick free gingival graft can be used for gingiva grafted onto ectopic oral sites retains
covering exposed root surfaces.40 When root the tissue characteristics of their donor site,
coverage is desired, a 1.25-mm or thicker graft which may affect the esthetics of the grafted
should be used. Recipient bed margins should site.45,46
include epithelial denudation of marginal and
Technique
papillary gingiva.
The thick graft undergoes greater primary The incision is made at the mucogingival junction
contraction, but the secondary contraction is min- along the length of recipient area and extended
imal because of thick lamina propria. Thick grafts to adjacent teeth; however, it should not involve
are more resistant to future recession. There tends the sulci of the nongrafted adjacent teeth. On the
to be an increase in root coverage over a 1-year mesial and distal aspects, the horizontal incision
period following surgery, known as creeping is connected to 2 vertical incisions at 90 or slightly
attachment, which is most often observed with divergent toward mucosa. A split-thickness
thick grafts.41 Once healed, thick grafts result in dissection is performed, leaving in place perios-
less esthetically acceptable appearance because teum and deepening the fornix. Preparation of

Fig. 5. (A) Preoperative view of a patient presenting for a 2-implant overdenture with a thin periodontium and
recession. (B) Intraoperative view after implant placement. The blue lines will be deepithelialized and closed in a
double papilla fashion (arrows) in order to increase the keratinized tissue. (C) The final closure over the connec-
tive tissue grafts. The arrows indicate the double papilla closure. These grafts increase keratinized tissue and
convert the patient to a thicker periodontal biotype.
434 Deeb & Deeb

the recipient bed should extend 3 mm past the SOFT TISSUE GRAFTING ON IMPLANTS
edge of the denuded root surface and include VERSUS TEETH
removal of aberrant frenum.
When root coverage is also the objective of the Free gingival grafting provides a wider zone of ker-
procedure, the initial horizontal incision should atinized tissue and promotes a tight adaptation of
be placed at the level of the desired new gingival denser tissue around implants, which allows better
level. The level of gingiva anticipated following plaque control and gingival health. Only a small
grafting can be either at the cemento-enamel junc- number of studies are available reporting long-
tion for Miller class I and II recession defects or term stability of exposed implant coverage
below it for class III and IV. The larger donor tissue compared with studies performed on teeth. From
is easier to stabilize, therefore rendering root available data, it is suggestive that gained soft tis-
coverage more successful. Thick grafts that cover sue coverage on teeth remains stable in the long
only 1 tooth are harder to suture and stabilize, term compared with implants (Figs. 6 and 7).
making them less predictable for use in root The technique used by Burkhardt and col-
coverage procedures. leagues47 to cover approximately 3 mm of soft tis-
Gingival grafts should be excised from the donor sue recession on buccal aspect of implants
site with recipient site size and shape in mind and resembles in every step techniques used to cover
contoured to the recipient area.36 exposed root surfaces with SCTG on teeth. How-
Suturing the graft to the recipient site should ever, despite achieving immediate recession
completely immobilize the graft to encourage the coverage of more than 100% following surgery,
anastomosing of capillaries by maintaining inti- that gain was not maintained and shrank to 66%
mate contact with the recipient site vascular bed. at the 6-month follow-up. In contrast, similar soft
The thicker grafts should be slightly stretched to tissue defects on implants were treated by Zuc-
keep capillaries open, thus enabling the establish- chelli and colleagues48 also using connective tis-
ment of the blood supply to the graft. Interrupted sue grafts. At 1 year they observed a mean
sutures are used on the edges. Sling sutures coverage of 96% and a significant increase in the
around grafted teeth ensure intimate contact of amount of keratinized tissue. The main difference
the graft interproximally and elimination of the between the two studies was the removal of the
dead space between graft and recipient bed. crown and reshaping and polishing of the implant
At present, free gingival grafts are not used as abutment before surgery, allowing better adapta-
often as in the past because of less than optimal tion between the graft and abutment. Reshaping
esthetics and a more uncomfortable postoperative and polishing the implant abutment closely
course than newer subepithelial techniques. resembles the way grafting is performed over

Fig. 6. (A) Adolescent patient with an inadequate zone of keratinized tissue around the facial aspect of the
mandibular incisors. (B) Split-thickness dissection of the anterior mandible to prepare the recipient bed for
palatal free gingival grafting. Note that the flap has been positioned apically in order to avoid coronal migration.
(C) Free gingival graft harvested from the palate. (D) Palatal donor site with Surgicel and Periacryl dressing over-
sewn with chromic gut suture. (E) Palatal graft sutured into place using chromic gut suture. (F) One week after
surgery showing an increased zone of attached tissue.
 Soft Tissue Grafting Around Teeth and Implants 435

Fig. 7. (A) A single-tooth implant showing a lack of keratinized tissue. (B) Supraperiosteal dissection in prepara-
tion for the free gingival graft. (C) A template in place before graft harvest. (D) The free gingival graft secured
into the recipient bed. (E) The final result showing increased keratinized tissue. Coverage of the porcelain at the
apical portion of the restoration was not achieved (and rarely is).

root surfaces with root planning, reshaping, condi- favored a prolonged period of revascularization
tioning, and placement of grafts in close proximity and delayed healing.51
to recipient surfaces. Addition of abutment and
crown modifications provides more space and Technique for Subepithelial Connective Tissue
better adaptation of the graft into the recipient Graft
site. Provisional crowns can be modified to guide Donor site for subepithelial connective tissue
and sculpt soft tissue during healing.49 graft
Masticatory mucosa on the palate between palatal
SUBEPITHELIAL CONNECTIVE TISSUE GRAFT raphae and maxillary posterior teeth is the most
common location for the donor site for SCTG
This technique is currently used in most soft tissue (see Fig. 16). It is composed of connective tissue
grafts performed in periodontal plastic surgery. and loosely organized glandular and adipose tis-
The connective tissue graft, also known as SCTG sue.52 The best-quality connective tissue is found
was introduced in 1980 by Langer and Calagna.50 closest to the teeth; however, harvesting tissue
Its use was described for root coverage and ridge closer than 2 mm to the teeth places those teeth
augmentation procedures. at risk for developing postoperative gingival reces-
The donor site was the patient’s palate, the graft sion caused by inadequate blood supply to the
was 1 to 2 mm thick, and split-thickness recipient apex of the retained flap.
bed preparation was suggested to provide double Surgeons harvesting SCTG from the palate must
blood supply to the newly added tissue graft.50 be familiar with the anatomy and characteristics of
The autogenous SCTG is divided by thickness of this donor site. It is important to avoid the nerves
the donor tissue into 3 categories: and vessels located in the greater palatine groove
1. Thin (0.5–0.8 mm) at the junction of vertical and horizontal palate. The
2. Average (0.9–1.4 mm) palatal vault height varies from 7 mm to 17 mm,
3. Thick (1.5 to >2 mm) with an average distance of 12 mm from the neuro-
vascular line.
The thickness of the graft proved to have an ef- The incision is started 2 mm from the soft tissue
fect on the amount of shrinkage and the rate of margin on the palatal aspect of the teeth and it
healing of the graft that occurred following sur- should end 2 mm above the neurovascular line.
gery. Rapid revascularization can be expected The width of donor tissue can therefore vary from
when uniform thin or intermediate grafts are 3 to 13 mm, with an average width of 8 mm.
placed on a periosteal recipient site. An uneven, The size of SCTG needed depends on the de-
thick graft placed on a site of denuded bone mands of the recipient site; however, for most
436 Deeb & Deeb

sites, 5 to 9 mm is an adequate width. Limitations Partially covered subepithelial connective

that the shallow vault represents as a donor site tissue graft
should be considered before surgery. Alternative Partially covered SCTG was originally described
sources for donor tissue are available and should by Langer and Langer.55 This technique can be
be used in such cases. Encroaching on neurovas- used for class I, II, and III recession defects; how-
cular structures can lead to bleeding and some de- ever, the increase in keratinized tissue obtained
gree of postoperative paresthesia to the palate. with this technique makes it more suitable for class
Donor sites can often be adequately stabilized by II and III recession defects in which keratinized
suturing (Figs. 11C and 16C). gingiva is deficient (Fig. 8).
SCTG can be removed from the palate by Blood supply is not as good for SCTG left
single-line incision (see Fig. 16B) or double parallel partially exposed as it is for the completely
incisions. Single-line incision allows for primary covered SCTG, therefore the donor tissue must
closure after removal of the graft (see Fig. 16C) be thick enough to survive over the avascular
and is used for larger grafts. Double parallel inci- root of the tooth.
sions are used for smaller grafts and provide grafts Partial graft coverage techniques offer several
with very uniform thickness. advantages, such as maintaining the preoperative
vestibular depth and position of mucogingival
Recipient Site for Subepithelial Connective junction, as well as augmentation of keratinized
Tissue Graft tissue as the exposed SCTG keratinizes over
when left exposed.56 Submerged grafts without
Modifications of preparation of the recipient site epithelial collar performed better esthetically,
have followed the introduction of the original tech- whereas exposed epithelial collar grafts resulted
nique. To eliminate vertical incisions, envelope in better gingival augmentation with similar results
flaps were explored for recipient sites with similar in root coverage.57 In spite of attempts to remove
success.53 Connective tissue grafts are used in the epithelium, it remains in 80% of the grafts.58
combination with many different recipient site
pedicle flap designs. SCTG can be either Completely covered subepithelial connective
completely covered or left partially exposed. Har- tissue graft
ris and colleagues54 compared 3 variations of Connective tissue grafts can be completely
recipient site flap design in conjunction with con- covered by the use of CAF. Vertical incisions can
nective tissue graft. Techniques including coro- be used for increased access and to facilitate cor-
nally positioned flap, double pedicle flap, and a onal repositioning; however, they decrease blood
tunneling procedure over an autogenous connec- supply and can cause scarring.
tive tissue graft were all effective in obtaining In the absence of keratinized tissue before graft-
root coverage and improving clinical parameters. ing, the flap to cover the graft consists of only

Fig. 8. (A) Preoperative clinical view showing 2 dental implants with inadequate keratinized tissue on the facial
aspect. (B) Supraperiosteal dissection to prepare a bed for free gingival grafting. The apical flap margin is sutured
to periosteum to prevent coronal migration during healing. (C) Palatal free gingival graft harvest. (D) Palatal
donor sites. These sites can be dressed with Surgicel and Periacryl. (E) Free gingival grafts sutured into place using
3.0 chromic gut. (F) Eight weeks after surgery showing increased keratinized tissue.
 Soft Tissue Grafting Around Teeth and Implants 437

mucosa. When covering an SCTG with a flap lack- TECHNIQUE FOR PEDICLE FLAP WITH
ing keratinized tissue, the outer surface over the VERTICAL INCISIONS
graft heals as nonkeratinized mucosa for a soft tis-
sue margin. To alter the surface of a new soft tis- The horizontal incision is made at the desired level
sue margin from mucosa to keratinized tissue of the future gingival margin, usually at the level of
once the graft has established its own blood sup- the CEJ. The incision extends to the interdental
ply, overlying mucosa can be released and apically area adjacent to the terminal grafted tooth. When
positioned leaving SCTG exposed to keratinize the second incision is used parallel to the first inci-
over. sion, it should be spaced as far apically from the
first one as the recession measures on the
PARTIAL-THICKNESS DOUBLE PEDICLE GRAFT exposed root. These incisions are then connected
with mesial and distal vertical incisions that extend
The use of a double pedicle flap should be consid- beyond the mucogingival junction to allow manip-
ered when the objective of grafting includes the in- ulation of the flap in the coronal direction. The
crease of keratinized tissue. The overlying double recipient bed is prepared with split-thickness
pedicle slides laterally interproximal papillary kera- dissection to free the flap from the periosteum.
tinized tissue over the grafted root surface and, SCTG is sutured in place, extending to the
compared with a coronally positioned pedicle edges of the recipient bed (Fig. 10B). The flap is
flap deficient in keratinized tissue, results in a then coronally advanced for as many millimeters
larger increase of keratinized tissue (3.0 mm vs as the recession measured before grafting (see
1.8 mm) (Fig. 9).59 Fig. 10).

Fig. 9. (A) Punch technique used for uncovering at stage 2 surgery. (B) Healing abutment placed at stage 2 sur-
gery. Note the horizontal ridge deficiency and narrow zone of attached tissue. (C) Papilla-sparing incision with
vertical releases is being elevated in preparation for connective tissue grafting to buccally augment the zone
of attachment. (D) Palatal connective tissue graft being sutured in place. (E) One week after surgery showing
buccal and vertical augmentation of the site. (F) The connective tissue donor site 1 week after surgery. (G) Final
restoration at 1 year after surgery showing improved buccal and vertical soft tissue contours.
438 Deeb & Deeb

Fig. 10. Connective tissue graft and pedicle flap (A) Preoperative view of lower left premolar area. Note receding
soft tissue margin with minimal amount of keratinized tissue present on tooth #21 and amalgam restoration ex-
tending onto root surface. (B) Intraoperative view showing recipient site with pedicle flap and SCTG sutured to
obtain desired root coverage apically of amalgam restoration. (C) Four weeks postoperatively, teeth #20 and #21
present with improved soft tissue support and good root coverage apically of margins of preexisting
restorations.

TECHNIQUE FOR ENVELOPE FLAP coronally to the CEJ. Papillary tissue is under-
mined but not reflected. The pouch must extend
This technique can also be called the single-tooth far enough laterally and apically to allow passive
tunnel or pouch technique. The SCTG is sutured placement of the SCTG. Dissection for this tech-
into a recipient tunnel donor site without reflecting nique is more difficult and tactile sensation is the
a traditional flap. The envelope flap maintains only method of negotiating the preparation of the
ample blood supply from the adjacent papillary, recipient site between periosteum and mucosa
overlying mucogingival and underlying mucoper- or gingiva. The suturing technique is also more
iosteal sides. challenging; however, fewer sutures are needed
A small scalpel blade is placed in the sulcus and because of good graft stability under the envelope
a split-thickness pouch is developed under the flap. The suturing technique is designed to pull the
surface of the mucogingival tissue. The recipient donor tissue into the tunnel preparation of the
bed preparation must extend to the papilla slightly recipient site (See Fig. 11).

Fig. 11. Connective tissue graft tunnel. (A) Preoperative clinical view showing root exposure and a thin zone of
keratinized tissue. (B) Subepithelial tunnel being prepared in a split-thickness dissection to receive the connective
tissue. (C) Single-incision technique used to harvest the connective tissue graft. (D) Connective tissue graft placed
into the subepithelial pocket. (E) Connective tissue graft and buccal flap sutured to the level of the CEJ. (F) One-
month postoperative visit showing root coverage as well as an increased zone of keratinized tissue.
 Soft Tissue Grafting Around Teeth and Implants 439

SEMILUNAR AND LATERAL SLIDING FLAPS thoroughly root planed and conditioned with either
citric acid,61 tetracycline, or ethylenediaminetetra-
Semilunar coronally positioned flaps and laterally acetic acid (EDTA). The implant surface can be
sliding flaps are mostly used without adding cleaned with air-power abrasive with sodium bi-
SCTG and are suitable for high vestibules with carbonate powder and application of tetracycline
thick and wide adjacent keratinized tissue that (Fig. 13).
can be transpositioned. Because of limitations of Elimination of endotoxins, demineralization, and
flap mobility and the numerous alternatives that removal of the smear layer provide exposure of
are now available, these techniques remain in dentinal tubules, which seems to be essential for
use for single teeth or implants in specific circum- new attachment procedures on the root surface.
stances (Fig. 12). Citric acid causes a greater degree of morpho-
logic alterations than EDTA62 or tetracycline
PINHOLE SURGICAL TECHNIQUE HCl63–65 and is considered to be a better root-
In recent years a novel surgical approach to root conditioning agent.
coverage, called the pinhole surgical technique, Deviating from the protocol can result in dam-
has been gaining exposure. Chao60 introduced it age to the tooth, demineralization, and lack of ce-
for Miller class I, II, and III recession defects and mentogenesis. Chemical conditioning of the
reported favorable predictability for root coverage dentin has been shown to stimulate the attach-
and defect reduction up to 18 months following the ment of fibroblasts65 as well as gingival keratino-
procedure. cytes, which could favor the reformation of a
junctional epithelium.66
ROOT SURFACE AND IMPLANT SURFACE Some clinical studies have failed to observe
TREATMENT improved outcomes of surgical technique when
using citric acid.67
Root or implant surface should be smooth and de-
contaminated before receiving the tissue graft. ALTERNATIVES TO AUTOGENOUS SOFT
Grooves or notches on the root surfaces should TISSUE GRAFTS
be properly contoured because they create dead
spaces between the graft and root surface. De- The concept of avoiding the secondary donor sur-
fects, calculus, and restorative materials should gical site adds great appeal to materials that repre-
be eliminated or reshaped with fine diamond burrs sent an alternative to autogenous donor sites for
or hand instruments. Root surface should be soft tissue grafting. Although these new materials

Fig. 12. Lateral sliding flap. (A) Canine with an inadequate zone of keratinized tissue. (B) Lateral pedicled flap
design just before split-thickness dissection. (C) Flaps mobilized and sutured into place using 4.0 chromic gut.
(D) Final result showing an increase in keratinized tissue.
440 Deeb & Deeb

Fig. 13. Allograft for connective tissue graft tunnel. (A) Preoperative clinical view showing recession and root
exposure. (B) Root preparation with EDTA after scaling and root planning. (C) Alloderm acellular dermal graft
being hydrated and measured. (D) Placement of Alloderm into recipient site tunnel preparation without flap
elevation. (E) Final closure of the coronally advanced flap over the Alloderm. (F) Postoperative clinical result,
showing complete root coverage in the upper left quadrant.

do not surpass the gold standard (SCTG), they do In systematic review evaluating esthetic soft
provide patient satisfaction and esthetics and are tissue management for both teeth and dental
available in abundance. implants, xenogeneic collagen matrix was compa-
rable with SCTG in terms of mean keratinized tis-
Allograft sue gain; however, it did not achieve the same
Allografts such as acellular dermal matrix (ADM) root coverage.73
have been used around teeth and implants to sub- Similarly, in another systematic review of the
stitute the autogenous connective tissue grafts, most effective techniques for soft tissue manage-
especially for larger recipient sites or when obtain- ment around dental implants, the technique using
ing autogenous tissue is not feasible and would an animal-derived collagen matrix was able to
lead to much higher postoperative discomfort. Al- achieve its goal, but at the cost of a worsened
lografts and autografts yield similar predictability esthetic outcome.30
for root coverage techniques; however, connec-
tive tissue autografts result in superior defect Guided Tissue Regeneration
coverage, higher keratinized tissue and attach-
Guided tissue regeneration (GTR) has been used
ment gain, and lower residual probing depths
for treatment of recession defects around teeth
(see Fig. 13).68–72
and implants using resorbable and nonresorbable
Allografts also provide an alternative to replace
barriers in combination with various bone grafts
an autogenous free gingival graft (Fig. 14).
and biologic agents.
Wei and colleagues73,74 conducted a study
GTR-based root coverage can be used suc-
comparing the effectiveness of ADM and free
cessfully to repair gingival recession defects.
gingival graft for increasing the width of attached
However, most studies that compared GTR and
gingiva. The results suggested that tissue formed
SCTG concluded that SCTG resulted in statisti-
at the ADM-treated site did not parallel any known
cally better root coverage, width of keratinized
mucosa and was more similar to scar tissue.
gingiva, and complete root coverage.76–79 Ten-
Xenograft year follow-up comparing SCTG and GTR for
root coverage found that the long-term stability
Xenografts that include thick collagen matrices of root coverage (ie, the reduction of recession
have been introduced as an alternative to auto- depth) and esthetic results perceived by patients
grafts or allografts for use as free gingival or con- were significantly better using SCTG compared
nective tissue grafts. with GTR surgery using bioabsorbable barriers.80
McGuire and Scheyer75 showed that xenoge-
neic collagen matrix with a CAF represents a viable
Living Cellular Construct
alternative to SCTG in the treatment of recession
defects, without the morbidity of soft tissue graft Living cellular constructs (LCC) are derived from
harvest. autogenous or allogenic sources.
 Soft Tissue Grafting Around Teeth and Implants 441

Fig. 14. Allograft for free gingival graft (A) Anterior mandibular preoperative view showing a narrow zone of
keratinized tissue. (B) Subperiosteal dissection in preparation for Alloderm augmentation. Note that the flap
has been sutured inferiorly to the apical periosteum. (C) Operative view showing the Alloderm secured in place
over the periosteal bed with interrupted and sling sutures. (D) Eight-week postoperative view showing an
increased zone of keratinized tissue.

Platelet-rich fibrin (PRF) is of autologous origin addition of PRF to a CAF in treatment of Miller
and has been reported in the literature as being class I and II recession defects resulted in superior
used for enhancing healing of the palatal donor root coverage compared with CAF alone.84
site81 and for papilla reconstruction.23 Search of site-appropriate tissue in the oral cavity
PRF was also used to treat multiple gingival re- has included application of living cellular sheet (LCS)
cessions.82 The natural fibrin architecture of PRF in oral soft tissue therapy as a free gingival graft.85,86
seems responsible for releasing large amounts of LCS is an allogenic graft composed of cultured
growth factors and matrix glycoproteins. These keratinocytes and fibroblasts in bovine collagen
biochemical components of PRF are involved in and has been used for more than 14 years to treat
wound healing and tissue regeneration.83 The patients with cutaneous wounds.87–90 (Fig. 15).

Fig. 15. (A) Preoperative view showing an inadequate zone of keratinized tissue in the anterior mandible. (B) Supra-
periosteal dissection completed in order to receive the graft. Note that the flap is secured inferiorly to the apical
periosteum. (C) The Mucograft is sutured into place using a combination of interrupted and sling sutures in order
to ensure graft immobility. (D) Final 12-week postoperative result showing an increased zone of keratinized tissue.
442 Deeb & Deeb

Based on histologic findings, the authors sug- comparisons of the mean keratinized tissue
gested that LCS-treated sites resembled gingiva gain.69
rather than alveolar mucosa. Compared with sites
treated with autogenous grafts, tissue generated Biologic agents
at LCS-treated sites presented with more site- Biologic agents have been explored in conjunction
appropriate tissue that was deemed superior in with soft tissue grafting to improve migration and
terms of color and texture match to adjacent un- differentiation of cells in grafted sites. The data
treated tissue, absence of scar formation, or ke- from systematic review by Fu and colleagues69
loidlike appearance as well as mucogingival concluded that the adjunctive use of biologic
junction alignment. Besides superior esthetics, agents did not exert a significant effect on mean
LCC also scored better in patient satisfaction; root coverage and mean amount of keratinized tis-
however it was inferior to free gingival graft in sue gain.

Fig. 16. SCTG ridge augmentation. (A) Preoperative view showing an inadequate bucolingual dimension under
pontic #8 in the anterior maxilla. (B) Intraoperative view showing harvesting of SCTG from the palatal donor site
by single-incision approach. (C, D) Donor site sutured (C) and covered with periodontal dressing (D). (E) Split-
thickness dissection for recipient site preparation using single vertical incision and tunnel preparation. Care
was taken to avoid disruption of gingival collars surrounding implants. (F, G) Sutures (arrows) were used to facil-
itate advancement of the graft into the recipient site. (H, I) SCTG sutured to recipient site before (H) and after (I)
the reinsertion of the implant-supported temporary prosthesis. (J) Healing after 8 weeks. Placement of connective
tissue graft augmented soft tissue support on the facial aspect of pontic #8. (K, L) Placement of connective tissue
graft in edentulous area enhanced the esthetics, volume of soft tissue, and papillae under the implant-supported
provisional prosthesis as shown by comparing before (K) and 8 weeks following surgery (L).
 Soft Tissue Grafting Around Teeth and Implants 443

Fig. 17. (A) Surgicel is sutured to the donor site. (B) Application of a hemostatic agent made of an oxidized poly-
anhydroglucuronic acid is easy and effective in improving hemostasis.

SOFT TISSUE GRAFTS FOR RIDGE Miller98 described a surgical technique using 1
AUGMENTATION vertical incision creating a tunnel between soft tis-
sue and bone, and inserting into it a connective tis-
Soft tissue grafts can be used for ridge augmenta- sue graft to augment deficient alveolar ridge. This
tion to improve esthetics and enhance pontic technique is useful for management of soft or
adaptation (See Fig. 16). hard tissue defects under existing restorations on
Seibert91,92 presented a classification of ridge teeth or implants as well as improving soft tissue
deformities and described a full-thickness onlay support around new ones.
grafting technique. Other investigators described
the use of connective tissue grafts to restore de-
Donor and Recipient Wound Site Protection
fects in bucolingual dimension.93–96 Allen and col-
leagues97 established that, following surgery, Donor sites often present with more postoperative
shrinkage was complete in 6 weeks and SCTG re- complications than recipient sites. Techniques for
mains volumetrically stable over several years. protection of donor sites include removable

Fig. 18. (A) Free gingival graft sutured to recipient site. (B) The placement of dressing is helpful in maintaining
vestibular depth and protecting the recipient site. (C) No root coverage is attempted for Miller class IV soft tissue
defect. (D) Placement of free gingival graft augmented the amount of keratinized gingiva and improved vestib-
ular depth, as is evident when comparing before (C) and 4 weeks following surgery (D).
444 Deeb & Deeb

devices or application of materials that stabilize attached gingiva. J Clin Periodontol 1985;12(8):
the clot and facilitate wound healing. 667–75.
Removable devices for the palate include stents 2. Wennstrom JL, Lindhe J. Role of attached gingiva
made from polymethyl methacrylate or vacuum- for maintenance of periodontal health. Healing
formed thermoplastic material as well as existing or- following excisional and grafting procedures in
thodontic retainers or dentures. Properly fabricated dogs. J Clin Periodontol 1983;10(2):206–21.
palatal stents should be secure and tightly adhering 3. Block MS, Kent JN. Factors associated with soft- and
to palatal tissue. The stent is important for larger and hard-tissue compromise of endosseous implants.
thicker grafts and it dramatically reduces postoper- J Oral Maxillofac Surg 1990;48(11):1153–60.
ative bleeding and discomfort. Patients with a ten- 4. Wennstrom JL. Lack of association between width
dency for slower healing, including smokers,99 of attached gingiva and development of soft tissue
make good candidates for the use of stents (Fig. 17). recession. A 5-year longitudinal study. J Clin Perio-
Materials used most frequently on palatal donor dontol 1987;14(3):181–4.
sites include oxidized cellulose (Surgicel) and 5. Bangazi F, Wennstrom JL, Lekholm U. Recession of
PRF.81,100 They have been credited as aiding in the soft tissue margin at oral implants. A 2-year lon-
healing and also adding to procedure time and gitudinal prospective study. Clin Oral Implants Res
cost. Periodontal dressing can be applied over 1996;7(4):303–10.
smaller donor sites for SCTGs (Fig. 18). 6. Warren K, Buser D, Lang NP, et al. Plaque-induced
Recipient sites can also be covered by a protec- peri-implantitis in the presence or absence of kera-
tive barrier. Cyanoacrylate tissue adhesive is tinized mucosa. Clin Oral Implants Res 1995;6:131.
applied in a thin layer over the junction of recipient 7. Silness J, Loe H. Periodontal disease in pregnancy.
site and graft once the graft is sutured in place. Re- II. Correlation between oral hygiene and peri-
ports using cyanoacrylate in the oral environment odontal condition. Acta Odontol Scand 1964;22:
have shown favorable healing and improved 121–35.
hemostasis101–103 and it has a safe record for in- 8. Friedman N. Mucogingival surgery. Tex Dent J
traoral use.104 Periodontal dressing offers good 1957;75:358–62.
adaptation over grafted areas and can be helpful 9. Miller PD Jr. Regenerative and reconstructive peri-
in maintaining an increased vestibular depth ob- odontal plastic surgery. Dent Clin North Am 1988;
tained with surgery. 32:287–306.
10. Genco RJ, Newman MG. Consensus report-
SUMMARY mucogingival therapy Ann Periodontol 1996;1:
702–6
Esthetic appearance and functional longevity for 11. Chu SJ, Tarnow DP. Managing esthetic challenges
teeth and implants often requires conversion of with anterior implants. Part 1: midfacial recession
unfavorable soft tissue traits to more favorable defects from etiology to resolution. Compend
ones. Improvement of tissue quality and quantity Contin Educ Dent 2013;34(7):26–31.
can be accomplished with many different tech- 12. Sullivan HC, Atkins JH. Free autogenous gingival
niques and materials and largely depends on clin- grafts. III. Utilization of grafts III. Utilization of
ical presentation of the case and familiarity of the grafts in the treatment of recession. J Periodontol
clinician with the procedures and materials avail- 1968;6:153.
able. Identification of causal factors, selection of 13. Miller PD. A classification of marginal tissue reces-
appropriate surgical technique, and evidence- sion. Int J Periodontics Restorative Dent 1985;5:9.
based material selection lead to predictable suc- 14. Armitage GC. Development of a classification sys-
cess when improving soft tissue characteristics tem for periodontal diseases and conditions. Ann
around teeth or implants. Periodontol 1999;4(1):1–6.
15. Kokich VO, Kokich VG, Kiyak HA. Perceptions of
ACKNOWLEDGMENTS dental professionals and laypersons to altered
The authors thank the following graduate dental esthetics: asymmetric and symmetric situa-
students at Virginia Commonwealth University for tions. Am J Orthod Dentofacial Orthop 2006;
their contributions of photographs for this publica- 130(2):141–51.
tion: Dr Anya Rost, Dr Fadi Hassan, Dr Sarmad Ba- 16. Chu SJ, Tan JH, Stappert CF, Tarnow DP. Gingival
kuri, Dr Diego A. Camacho, and Dr Nicholas Kain. zenith positions and levels of the maxillary anterior
dentition. J Esthet Restor Dent 2009;21(2):113–20.
17. Kan JY, Rungcharassaeng K, Umezu K, et al. Di-
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