Clinical Oral Investigations

https://doi.org/10.1007/s00784-022-04697-2

RESEARCH

Soft tissue phenotype modification impacts on peri‑implant stability:

a comparative cohort study
Cho‑Ying Lin1,2 · Pe‑Yi Kuo1 · Meng‑Yao Chiu1 · Zhao‑Zhao Chen3 · Hom‑Lay Wang3

Received: 24 April 2022 / Accepted: 21 August 2022

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
Objectives  Soft tissue phenotype modification (STPM) could be performed to maintain peri-implant health. Therefore,
the aim of the study was to analyze tissue alteration around implants following soft tissue phenotype modification during
implant uncovering surgery.
Materials and methods  Patients who had STPM (either pouch roll or modified roll technique) during implant second-stage
surgery with at least 12-month follow-up were included. Clinical and radiographic parameters including mucosal tissue
thickness (MTT), recession (REC), keratinized mucosa width (KMW), probing pocket depth (PPD), marginal bone loss
(MBL), emergence profile, and emergence angle were extracted from 2-week, 2-month, and 12-month visits after second-
stage surgery.
Results  Twenty-eight patients with 33 implants that fulfilled the inclusion criteria were included. After soft tissue pheno-
type modification, at 2 weeks, REC was negatively correlated to mean MTT at mid-buccal site (r =  − 0.41, p = 0.018) and
borderline correlated at mid-lingual site (r =  − 0.343, p = 0.051). Stable KMW was maintained from 2 weeks to 12 months
with minimal shrinkage rate (3 ~ 14%). MBL change was limited (0.24 ~ 0.47 mm) after STPM. All implants had shallow
PPD (≤ 3 mm) with the absence of bleeding on probing. Emergence angle at the mesial side, however, was significantly
correlated to surgical techniques, which indicated pouch roll technique would have 6.96 degrees more than modified roll
technique (p = 0.024).
Conclusions  Soft tissue phenotype modification, either pouch roll or modified roll technique, during uncovering surgery
resulted in favorable clinical outcomes. Thin mucosal tissue thickness and pouch roll technique are the factors related to
more recession at 2 weeks. Pouch roll technique could influence the restorative design by having a wide emergence angle
at the mesial side.
Clinical relevance  Modified and pouch roll techniques during uncovering surgery were viable methods to yield favorable
peri-implant health, while the preciseness of pouch roll technique was required to avoid mucosal recession and inadequate
restorative design.

Keywords  Peri-implant health · Soft tissue phenotype modification · Soft tissue augmentation · Second-stage surgery ·
Maintenance · Supportive treatment · Peri-implant keratinized mucosa

Introduction

Soft tissue augmentation around implants has been centered

in increasing width of keratinized mucosa (KMW) as well
* Cho‑Ying Lin as mucosa tissue thickness [1–5]. It has been thought to
[email protected] not only maintain natural teeth health but also peri-implant
1 health and stability [6]. However, with regard to the need
Department of Periodontics, Chang Gung Memorial
Hospital, Taipei, Taiwan of KMW to maintain dental implant health, the evidence
2 remained to be limited [7]. Nevertheless, lack of adequate
Chang Gung University, Taoyuan city, Taiwan
KMW has been associated with more plaque deposition,
3
Department of Periodontics and Oral Medicine, School more inflammation, higher mucosal recession, and greater
of Dentistry, University of Michigan, Ann Arbor, MI, USA

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attachment loss [8], or even higher risks of peri-implant dis- June. All included patients had to meet the following inclu-
ease in erratic maintenance compliers [9]. sion criteria:
So far, the use of autogenous graft–based techniques,
especially free gingival graft placement, has been regarded 1. Patient treated with at least one bone leveled 3i ­implant*:
as the gold standard to increase KMW as well as the vesti- 3.25, 4, and 5 mm in diameter and 8.5, 10, and 11.5 mm
bule depth [5, 10]. Likewise, the autologous connective tis- in length, and primary stability was obtained with inser-
sue graft has been widely recommended for mucosal tissue tion torque ≥ 20Ncm after placement.
thickness enhancement [5], due to its favorable thickness 2. Implant(s) is/are restored with fixed prosthesis (single
with minimal shrinkage in long-term follow-up when com- crown and splinted crown, which excluded the ones with
paring to other soft tissue graft approaches [10, 11]. The pontic(s)).
necessity of augmenting mucosal tissue thickness might be 3. Informed consent had been obtained prior to implant
attributed to prevent peri-implant bone loss and to enhance uncovering.
esthetic outcomes [3, 10, 12, 13]. The difference in the 4. Intact clinical and radiographic data was available, and
amount of bone remodeling could be attributed to the dif- the patient followed the recommended supportive post-
ference in mucosal tissue thickness, which has been believed implant treatment during the 12-month loading period
to be the result of supracrestal tissue height (i.e., biological of implants.
width) establishment [14–16]. Moreover, one cross-sectional 5. Implant was classified as score 0 of peri-implant bleed-
study even suggested that thin mucosal tissue was more ing index [26].
likely to have peri-implantitis [17]. Not surprisingly, thick
mucosal tissue often has better esthetic outcomes because Patients were excluded from this study if they have one
of its ability in achieving better tissue contour [18], mask- of the following criteria:
ing effect from metal abutment [19, 20] and creating papilla
after prosthesis fabrication [21]. 1. Uncontrolled systemic disease, such as hypertension,
Soft tissue phenotype modification around the implant diabetes.
could be performed at different time points without causing 2. Untreated periodontitis.
any significant reduction in both KMW and mucosal tissue 3. Implant was placed immediately after extraction.
thickness [22]. It is often recommended to perform soft tis- 4. Guided bone regeneration was performed at the time
sue phenotype modification, either pouch roll [23], or modi- of soft tissue phenotype modification.
fied roll technique [24], during implant uncovering surgery, 5. Implant with ≥ 3 mm in KMW.
since this procedure can be done simultaneously without the 6. History of radiation therapy on head and neck regions.
need of an additional surgery [25]. However, data on how 7. Heavy smokers (more than 0.5 pack per day).
both procedures influence the peri-implant clinical param- 8. Patient with pregnancy.
eters have not been thoroughly investigated or compared. 9. Same surgical site with failed implant history.
Therefore, the primary purpose of this retrospective cohort 10. Patient who did not comply to the recommended sup-
study was to analyze the soft tissue alteration during the portive treatment was regarded as erratic complier.
early healing process and the change after loading, includ-
ing initial mucosa tissue thickness, KMW, probing pocket The study protocol was conducted according to revised
depth (PPD), mucosal recession (REC), and radiographic version of Helsinki Declaration in 2013, and it was approved
bone level during the 12-month period. The secondary out- by institutional review board of Chang Gung memorial hos-
come of this study was to assess the correlation between all pital (IRB: 202101533B0). Following STROBE statement,
clinical parameters to the following two variables: surgical the cohort study was performed.
techniques and restorative designs of the crown.
Clinical procedure

After local anesthesia, either modified roll technique [24]

Materials and methods (Fig. 1A–H) or pouch roll technique [23] (Fig. 1I–P) was
performed around implants with 4-mm or 6-mm healing
Patient selection and study design abutment. In the pouch roll technique, part of the U-shaped
flap above the implant was de-epithelized and rolled up
The present retrospective cohort study included patients with then tugged in under the buccal flap. When modified roll
at least one implant placement 4 to 6 months prior to stage technique was chosen, H-shaped incisions were performed,
2 surgery, and all implant surgeries had been performed by and part of the palatal/lingual flap was taken to enhance
the same surgeon (CYL) between 2019 January and 2020 mucosa tissue thickness of buccal flap (Fig. 2). Rotation

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Clinical Oral Investigations

Fig. 1  Modified roll technique (A, B) or pouch roll technique (I–K) cases (modified roll (C–H); pouch roll (L–P)) were under supportive
was performed for pedicle soft tissue augmentation around implants, treatment at 2 weeks, and 2 and 12 months after surgery
and 4-mm healing abutment was placed after flap preparation. All

Fig. 2  The colored diagraph described different designs of roll flap around implant from cross-sectional view. Yellow: buccal flap; red: soft tis-
sue above the implant; blue: lingual/ palatal flap

flap in both techniques were stabilized with 5–0 (PDS*II, titanium patient-specific abutment, was then constructed
Polydioxanone, ETHICON) or 6–0 (PROLENE, ETHICON) by a board-certified prosthodontist, and the final data was
suture for wound closure. Post-operative instructions were collected 12 months after implant loading. All patients had
instructed verbally, and the medications were prescribed been through tailored supportive post-implant treatment,
(acetaminophen 500 mg, tid for 5 days) for pain control. and the interval was 3 months for the 12-month period. As
Systematic antibiotics (amoxicillin 375 mg, tid for 5 days) for the regimen, routine coronal prophylaxis and mechani-
were also given if symptom and signs of infection was cal debridement were performed with ultrasonic device and
noted during post-operative phase. Sutures were removed titanium curettes, and oral hygiene reinforcement was also
2 weeks after surgery, and surgical wounds were followed applied at every visit with adequately designed interdental
2  months afterwards. The implant prosthesis, including brush and superfloss for homecare maintenance.

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 Clinical Oral Investigations

Data collection and outcome measurement 1. Marginal bone level (MBL): mesial and distal bone level
was defined as the distance from the shoulder of the
Clinical parameters (mucosa tissue thickness, REC, KMW, implant to the first bone-to-implant contact at proxi-
PPD) were measured with periodontal probe (PCP-UNC 15 mal sites. The measurement accuracy was 0.1 mm, and
tip, HU-Friedy, Chicago, IL) with an accuracy of 0.5 mm the length of the implant was utilized as the reference
before and after abutment connection procedure. for deformation correction. The alteration of proximal
Other clinical and radiographic measurements were con- bone level was followed from baseline to 2 months and
ducted as follows: 12 months after surgery.
2. Emergence angle [27] and emergence profile [27]: the
1. Mucosal tissue thickness around implant (MTT): Sound- angle was measured in periapical film with digital cali-
ing technique was performed with periodontal probe per, and the profile type was categorized with straight,
above the implant with 3 points (mesial, central, distal) concave, and convex.
prior to surgery under local anesthesia.
2. Mucosal recession (REC): the distance from the top of
the abutment to the margin of mucosa at 6 sites around Statistical analysis
implants (mesio-buccal, mid-buccal, disto-buccal,
mesio-lingual, mid-lingual, and disto-lingual) at the vis- SPSS25 (IBM Corp. Released 2017. IBM SPSS Statis-
its of 2 weeks, 2 months after surgery, and 12 months tics for Mac, Version 25.0) statistics package program
after loading. was used for statistical analysis. Descriptive statis-
3. Keratinized mucosa width (KMW): Periodontal probe was tics of mucosal tissue thickness, REC, KMW, PD, and
used to measure KMW at 3 buccal sites (mesio-buccal, mid- MBL at different time points in 2 different techniques
buccal, disto-buccal) of the implant at the visits of 2 weeks, are reported as means ± standard deviations. Intergroup
2 months after surgery, and 12 months after loading. and intragroup comparisons were performed by means
4. Probing pocket depth (PPD): Periodontal probe was of the non-parametric Mann–Whitney U test and the
used to measure PPD at 6 spots around implants (mesio- Wilcoxon signed-rank test, respectively. The chi-square
buccal, mid-buccal, disto-buccal, mesio-lingual, mid- association test (χ 2) was used to compare EP distribu-
lingual, and disto-lingual) at the visits of 2 months after tion in 2 different techniques. The association between
surgery and 12 months after loading. clinical parameters and EA was evaluated by Spearman’s
Rank correlation coefficient. Univariate linear regres-
Radiographic measurements were followed with paral- sion methods were performed to investigate factors to EA
leled taken peri-apical films by an independent calibrated and recession. p < 0.05 was accepted for the significance
examiner (MYC) (Fig. 3). level of the tests.

Fig. 3  Radiographic measurements were followed with paralleled taken peri-apical films. Abbreviation: Marginal bone loss (MBL), emergence
profile (EP), and emergence angle (EA) were measured at mesial and distal sides of implants

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Results change at mesial site achieved significance after loading

(2 ~ 12 months) in pouch roll group (p = 0.006). Neither
Study population PPD nor REC was correlated to MBL at all time points.

Twenty-eight patients with 33 implants that fulfilled the Correlation between implant restorative design
study criteria were included. Totally, 16 patients (18 and other factors
implants) received modified roll technique, and 12 patients
(15 implants) had pouch roll technique during uncovering Generally, the pouch roll group resulted in more REC than
surgery. However, four participants (one in pouch roll and modified roll group at all time points. For example, in mid-B
3 in modified roll group) missed the 4 months recall due REC at 2 weeks, pouch roll group had 1.02 mm more reces-
to Covid-19 pandemic. sion than modified roll group with statistical significance
(p = 0.025, B = 1.017). Focusing on the change of REC from
2 weeks to 2 months, the intragroup difference with statisti-
Demographic data and clinical and radiographic cal significance could only be found in the modified roll
measurements group at mid-buccal site (p = 0.031), while the intergroup
difference did not exist between two surgical approaches at
The demographic data and measurements are summarized either site of implants (Fig. 6a, b).
in Table 1. The inter-examiner measurement agreement Based on the change of KMW (2 weeks–2 months), the
was 92% within 0.2 mm by repeating measurement 10 shrinkage of graft was 0.43 mm (5%) in modified roll group
times. Interestingly, at baseline, the modified roll group and 0.71 mm (14%) in pouch roll group (Table 1). Despite
possessed thicker mucosa tissue thickness than the pouch the lack of significant difference between groups, the sta-
roll group (3.1 vs. 2.4 mm) with a significant difference. tistical change could be observed in the pouch roll group
At the 2 weeks visit, mid-buccal REC was negatively cor- (p = 0.011). From 2 to 12 months, the alteration of KMW
relating to mean mucosa tissue thickness mean (r =  − 0.41, was minimal without intergroup difference (p = 0.238), while
p = 0.018), and mid-lingual REC was borderline cor- the intragroup difference could be noted in modified roll
related as well (r =  − 0.343, p = 0.051) after adjusting group (p = 0.033) (Fig. 7).
the difference noted in the baseline. The statistical dif- The correlation between the restorative design of the
ference disappeared at 2 months recall. For REC change implant and clinical data was assessed (Table 2). Intergroup
(2 weeks–2 months), both mid-buccal/mid-lingual RECs difference was not noted in terms of emergence profile
were positively borderline correlated with mean mucosa distribution. REC 2 weeks at disto-lingual, mesio-lingual
tissue thickness (r = 0.333, p = 0.058; r = 0.338, p = 0.054). areas were positively correlated to emergence angle at dis-
Regarding REC at different time points, mean REC at tal side (r = 0.389, p = 0.025) and at mesial side (r = 0.366,
6 sites presented a small but insignificant change from p = 0.036). However, the positive correlation remained at
2  weeks to 2  months, while the lingual side of REC only mesio-lingual site during the 2-month period (r = 0.392,
showed different tendency lines when compared to buccal p = 0.024). No correlation could be found between MBL
sites except for the mesio-lingual site (Fig. 4). change and emergence angle at mesial side among all exami-
For KMW, modified roll technique preserved signifi- nation visits (2 months ~ baseline, 12 months ~ 2 months).
cantly more KMW than the pouch roll group at 2 months Additionally, emergence angle at mesial side was signifi-
(p = 0.048). However, the statistical differences between cantly correlated to surgical techniques, which indicated
groups disappeared 2 months after surgery (Table 1). the pouch roll technique would cause 6.96° wider than the
PPD and MBL were stable in both groups without any modified roll technique (p = 0.024) (Table 2).
differences at all time points. PPD was not correlated to
REC and MBL from baseline to 2 months except for the
mid-lingual site of implants. Furthermore, the regres- Discussion
sion of analysis indicated that an increase of 1 mm mid-L
REC would have 0.3 mm less PPD at 2 months follow-up Surgical approaches of soft tissue phenotype modification
(p = 0.026). The MBL change was 0.24 ~ 0.28 mm from could be performed at various time points [2, 3, 22, 25, 28],
baseline to 2 months, and the alteration was 0.1 ~ 0.16 mm and the application with concomitant uncovering surgery
after abutment connection from 2 to 12 months (Table1) was efficient to achieve soft tissue enhancement with abut-
(Fig.  5a, b). Both soft tissue phenotype modification ment connection at the same time [28]. Results obtained
groups presented limited MBL from implant placement from this study confirmed that soft tissue phenotype modi-
to 12 months follow-up. However, the calculated MBL fication, either pouch roll or modified roll technique, could

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Table 1  The demographic data and measurements

Surgical approach Mod Pouch

Demographic data
  Patient/implant (N) 16/18 12/15
  Gender (female; male) (N) (patient level) 7; 9 6; 6
  Tooth site (N) (implant level) Upper: Incisor(1)/canine(1)/ Upper: Incisor(0)/canine(0)/
premolar(1)/molar(8) premolar(2)/molar(5)
Lower: Lower:
Premolar(1); molar(6) Premolar(0); molar(8)
  Restorative design (implant level) Single crown: 13 Single crown: 10
Splinted crown: 5 Splinted crown: 5
Measurements Mean ± SD Min–Max Mean ± SD Min–Max
MTT mean* 3.13 ± 0.56 2.33 2.42 ± 0.41 2–3.33
REC 2 weeks
  Disto-buccal* 0.47 ± 1.1  − 2–2 1.4 ± 1.24  − 1–3
  Mid-buccal* 0.25 ± 1.05  − 2–2 1.27 ± 1.44  − 2–3
  Disto-buccal 0.69 ± 1.24  − 2–2 1.1 ± 1.23  − 1–3
  Disto-lingual 1.28 ± 1.02  − 1–3 1.6 ± 1.06  − 1–3
  Mid-lingual 1.25 ± 1.05  − 1–3 1.73 ± 1.32  − 2–3
  Mesio-lingual 0.42 ± 1.41  − 2–3 1.27 ± 1.16  − 1–3
REC 2 months
  Disto-buccal 0.72 ± 0.99  − 1–2.5 0.93 ± 1.18  − 1–3
  Mid-buccal 0.72 ± 0.83  − 1–2 0.77 ± 1.56  − 2–3
  Disto-buccal 0.61 ± 0.88  − 1–2 0.6 ± 1.44  − 2–3
  Disto-lingual 1.14 ± 0.76 0–2.5 1.73 ± 0.96 0–3
  Mid-lingual 1.39 ± 1.13 0–3 2 ± 1.18 0–3
  Mesio-lingual 0.56 ± 1.44  − 2–2.5 1.37 ± 0.97 0–2.5
REC change 2 months–2 weeks
  Disto-buccal 0.25 ± 0.73  − 1–1.5  − 0.47 ± 1.47  − 3–2
  Mid-buccal 0.47 ± 0.74  − 1–2  − 0.5 ± 2.24  − 5–3.5
  Disto-buccal  − 0.08 ± 1.02  − 2.5–2  − 0.5 ± 1.7  − 5–2
  Disto-lingual  − 0.14 ± 0.74  − 1.5–1 0.13 ± 1.25  − 2–3
  Mid-lingual 0.14 ± 0.7  − 1–1 0.27 ± 1.53  − 2–4
  Mesio-lingual 0.14 ± 0.38  − 0.5–1 0.1 ± 0.89  − 1–2
REC 12 months
  Disto-buccal  − 0.07 ± 0.26  − 1–0 0 0
  Mid-buccal  − 0.07 ± 0.26  − 1–0 0 0
  Disto-buccal  − 0.07 ± 0.26  − 1–0 0.04 ± 0.13 0–0.5
  Disto-lingual 0 0 0.07 ± 0.27 0–1
  Mid-lingual 0.27 ± 0.46 0–1.5 0.11 ± 0.29 0–1
  Mesio-lingual  − 0.03 ± 0.3  − 1–0.5 0.07 ± 0.27 0–1
REC change 12 months–2 weeks
  Disto-buccal  − 0.9 ± 0.83  − 2.5–0  − 0.89 ± 1.21  − 3–1
  Mid-buccal  − 0.77 ± 0.75  − 2–0  − 0.71 ± 1.6  − 3–2
  Disto-buccal  − 0.7 ± 0.82  − 2–1  − 0.5 ± 1.41  − 3–2
  Disto-lingual  − 1.13 ± 0.79  − 2.5–0  − 1.64 ± 1.01  − 3–0
  Mid-lingual  − 1.2 ± 1.22  − 3–1.5  − 1.89 ± 1.26  − 3–0.5
  Mesio-lingual  − 0.73 ± 1.19  − 2.5–2  − 1.29 ± 0.99  − 2.5–0
KMW
  2 weeks 5.57 ± 1.5 4–9.33 5 ± 1.82 2.33–9
  2 months* 5.15 ± 1.3 3.67–9 4.29 ± 1.88 1.67–9
  2 months–2 weeks  − 0.43 ± 0.86  − 1.67–1  − 0.71 ± 0.82  − 2–0.33

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Table 1  (continued)
Surgical approach Mod Pouch

  2 months–2 weeks shrinkage (%)  − 0.05 ± 0.16  − 0.24–0.25  − 0.14 ± 0.18  − 0.45–0.17

  12 months 4.44 ± 1.25 3–6.67 4.12 ± 2.05 2–9.33
  12 months–2 months  − 0.56 ± 0.85  − 0.2–0.67  − 0.29 ± 1.04  − 1.67–1.33
  12 months–2 months shrinkage (%)  − 0.11 ± 0.17  − 0.35–0.13  − 0.03 ± 0.26  − 0.44–0.33
PPD 2 months
  Disto-buccal 2.44 ± 0.51 2–3 2.4 ± 0.74 1–4
  Mid-buccal 2.61 ± 0.61 2–4 2.53 ± 0.74 2–4
  Disto-buccal 2.67 ± 0.69 1–4 2.67 ± 0.82 1–4
  Disto-lingual 2.89 ± 0.68 2–5 2.53 ± 0.74 1–4
  Mid-lingual 2.56 ± 0.92 1–5 2.6 ± 0.91 1–4
  Mesio-lingual 2.61 ± 0.61 2–4 2.47 ± 0.74 1–4
PPD 12 months
  Disto-buccal 3 ± 0 3 2.64 ± 1.15 1–5
  Mid-buccal 2.67 ± 0.82 1–4 2.64 ± 1.01 1–4
  Disto-buccal 2.93 ± 0.96 2–5 2.71 ± 0.99 1–5
  Disto-lingual 2.67 ± 0.62 2–4 2.86 ± 1.03 1–5
  Mid-lingual 2.8 ± 0.77 2–4 2.71 ± 0.83 2–5
  Mesio-lingual 2.87 ± 0.74 2–4 2.86 ± 0.95 1–5
PD change 12 months–2 months
  Disto-buccal 0.53 ± 0.52 0–1 0.21 ± 1.19  − 1–2
  Mid-buccal 0.07 ± 1.1  − 2–2 0.14 ± 0.95  − 1–2
  Disto-buccal 0.33 ± 1.11  − 2–2 0 ± 1.3  − 2–2
  Disto-lingual  − 0.27 ± 0.88  − 2–1 0.21 ± 0.89  − 1–2
  Mid-lingual 0.13 ± 0.92  − 1–2 0 ± 0.88  − 2–1
  Mesio-lingual 0.27 ± 0.88  − 1–2 0.29 ± 0.83  − 1–2
  MBL baseline
  Mesial  − 0.03 ± 0.71  − 2.1–0.86 0.09 ± 0.31  − 0.47–077
  Distal 0.05 ± 0.51  − 1.1–0.87 0.1 ± 0.19  − 0.38–0.43
MBL 2 months
  Mesial 0.26 ± 0.67  − 2.13–1.3 0.24 ± 0.21  − 0.24–0.67
  Distal 0.24 ± 0.52  − 1.2–1.32 0.28 ± 0.17 0–0.64
MBL change (2 months–baseline)
  Mesial 0.3 ± 0.67  − 0.74–1.94 0.14 ± 0.32  − 0.53–0.74
  Distal 0.19 ± 0.47  − 0.44–1.25 0.18 ± 0.26  − 0.24–0.64
MBL 12 months
  Mesial 0.41 ± 0.31  − 0.3–1.05 0.37 ± 0.19 0.17–0.82
  Distal 0.34 ± 0.35  − 0.3–1.13 0.33 ± 0.15 0–0.53
MBL change (12–2 months)
  Mesial 0.16 ± 0.79  − 0.67–2.93 0.13 ± 0.15  − 0.14–0.46
  Distal 0.1 ± 0.47  − 0.9–0.96 0.15 ± 0.24  − 0.48–0.42
MBL change (12 months–baseline)
  Mesial 0.47 ± 0.85  − 0.61–2.9 0.27 ± 0.38  − 0.6–0.93
  Distal 0.34 ± 0.58  − 0.51–1.67 0.24 ± 0.26  − 0.43–0.53
*
 Statistically significant differences (p < 0.05) (Mann–Whitney U test)
Mod modified roll technique; pouch pouch roll technique; MTT mucosal tissue thickness; REC recession, the distance from the top of abutment
to margin of mucosa; KMW keratinized mucosal thickness; PD pocket depth; MBL marginal bone loss; SD standard deviation

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 Clinical Oral Investigations

Fig. 4  From 2 weeks to 2 months after surgery, marginal mucosa at 6 points presented gentle alteration without significant difference. Abbrevia-
tion: REC, recession; DB, disto-buccal; mid-B, mid-buccal; MB, mesio-buccal; DL, distolingual; mid-L, mid-lingual; ML, mesio-lingual

Fig. 5  The change of marginal bone level at a mesial and b distal sides in different surgical approaches from 2 to 12  months after surgery.
Abbreviation: MBL, marginal bone loss; m, mesial; d, distal; Mod, modified roll technique; Pouch, pouch roll technique

gain mucosal tissue thickness and KMW as well as to achieve PPD, decrease plaque index, and prevent soft tissue dehis-
required supracrestal tissue height and nice tissue contour cence [4, 10, 13], thus promoting peri-implant health and sta-
around implants for implant long-term stability and esthetics. bility. Result from this study indicated that soft tissue pheno-
This is in line with literature that showed soft tissue pheno- type modification can effectively increase buccal KMW (all
type modification was aimed to improve mucosal thickness had ≥ 2 mm) with minimal shrinkage (3 ~ 14%) from 2 weeks
and keratinized mucosal width, maintain stable MBL, reduce to 12 months regardless of which surgical procedures were

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Clinical Oral Investigations

Fig. 6  The change of marginal mucosa at a mid-buccal and b mid-lingual sides in different surgical approaches from 2 weeks (W) to 12 months
(M) after surgery. Abbreviation: REC, recession; Mod, modified roll technique; Pouch, pouch roll technique

Fig. 7  The change of kerati-

nized mucosa at in different
surgical approaches from
initial to 12 months (M) after
surgery. Abbreviation: KMW,
keratinized mucosa width; Mod,
modified roll technique; Pouch,
pouch roll technique

performed. This implied that soft tissue phenotype modifica- Our data also showed that factors that influence the out-
tion is beneficial for implant stability, which was in agree- comes of soft tissue phenotype modification are baseline
ment with literature that demonstrated KMW ≥ 2 mm is an REC and tissue phenotype (thin versus thick). Interest-
adequate amount needed to maintain long-term peri-implant ingly, our study found thicker mucosa tissue thickness had
health [8, 9, 29]. Furthermore, the amount of shrinkage was wider fluctuation of REC from 2 weeks to 2 months after
less than free autograft and substitute materials in related surgery. Hence, it may imply that for implant prosthesis
studies [30–33], which indicated both pouch roll and modi- fabrication especially in esthetic demanding area, it should
fied pouch roll techniques are good soft tissue phenotype not be performed before 2 months to avoid potential soft
modification procedures in terms of their tissue stability. tissue alterations. Besides, the correlations between REC

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 Clinical Oral Investigations

Table 2  The restorative design of implant in different surgical tech- illustrated that both treatment procedures are equally effec-
niques tive. According to Bassetti’s article, soft tissue phenotype
Restorative design Modified Pouch roll technique modification via various roll envelope flaps could enhance
roll tech- both KMW and mucosa tissue thickness [28]; however, in
nique this specific review, no direct comparison was made among
Emergence profile: 5/3 7/5 different roll techniques. It was worth noting that REC at
concave (m/day) (N) mesio-lingual was positively correlated to emergence angle
Straight (m/day) (N) 7/8 5/5 at mesial side, and pouch roll technique had almost 7°
Convex (m/day) (N) 6/7 3/5 wider emergence angle at mesial side than the modified roll
Emergence angle mesial (°) 20.44 (9.5) 26.47 (7.51) * technique. The emergence angle around implants has been
(mean/SD) shown to influence the prosthesis contour design and poten-
Emergence angle distal (°) 11.58 (3.8) 22.85 (9.52) tial MBL [27, 35, 36].
(mean/SD)
Several limitations do exist in this current study. Because
*
 Statistically significant differences (p < 0.05) (Mann–Whitney U test) of the nature of retrospective cohort study, it could inevita-
N sample size, EP emergence profile, EA emergence angle, m mesial, bly weaken the quality of the evidence. Despite the fact that
d distal all included implants were with the same design from the
same company (BIOMET 3i, Implant Innovations Inc., Palm
Beach Gardens, FL, USA), a larger sample size with a longer
2 weeks at disto-lingual, mesio-lingual areas were posi- follow-up is often desirable. Hence, continued documenta-
tively correlated to emergence angle at proximal sides (dis- tion of the current study is also ongoing so the longer term
tal: r = 0.389, p = 0.025; mesial: r = 0.366, p = 0.036). The of data will be available at a later time. Nonetheless, this
r value implied that initial REC prior to restoration could was the first study investigating tissue alteration after differ-
be one of the indicators but not the determinant factor, and ent soft tissue phenotype modifications during early healing
several other factors could have impacts on emergence angle, process, which shall provide a valuable information to the
such as the depth of implant placement, discrepancy from clinical practice. Furthermore, the reference of peri-implant
platform to crest of adjacent tooth, and the mucosal tun- mucosa was somehow altered following prosthesis place-
nel around implants [34]. In addition, the emergence angle ment, which could also have impacts on the values of PPD
in current study was evaluated from 2-dimensional images, and REC. Therefore, future study with a volumetric analysis
which might genuinely weaken the impact of lingual flap to might minimize this concern by eliminating the drawback
restoration design. Even though both soft tissue phenotype with superimposition images. Moreover, despite the debate
modification approaches could achieve similar outcomes, of repetitive radiation exposure, 3-dimensional radiographic
pouch roll technique might cause more REC because of the analysis might be essential to depict the panoramic view of
gap between the incision and actual implant position. There- peri-implant bone level change and restorative design. To
fore, pouch roll technique probably was more suitable in eliminate the bias above, a prospective well-design rand-
single-implant cases since it can have less REC so a better omized clinical trial with adequate subject number and long-
restorative design can be fabricated. term observations was required for further investigation.
Data obtained from this study showed that after soft tis-
sue phenotype modification treatment, all implants had less
than 3-mm PPD with absence of bleeding on probing, and Conclusions
this outcome further supports the benefit of this modifica-
tion treatment. Furthermore, only limited (0.14 ~ 0.3 mm) With the limitations of this study, soft tissue phenotype
MBL change was observed from baseline to 2 months sug- modification at the time of implant uncovering surgery
gesting soft tissue phenotype modification can minimize resulted in favorable clinical outcomes. Among all factors,
the amount of initial bone remodeling, by establishing the thin mucosal tissue thickness and pouch roll technique are
required supracrestal tissue height. It was not surprising to the factors related to more recession. Pouch roll technique
find bone level becomes stable from 2 to 12 months (with could influence the restorative design by having a wide
prosthesis in function) in this study. This phenomenon con- emergence angle at the mesial side.
firms that once the required supracrestal tissue height was
formed, stable bone level could be anticipated overtime as Supplementary Information  The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00784-0​ 22-0​ 4697-2.
long as patient complied with the recommended supportive
peri-implant care.
Author contribution  Cho-Ying Lin: concept/design, data collection/
Results from this study found that the intergroup dif- analysis/interpretation, drafting article, editing articles.
ference did not exist beyond 2 months after surgery which Pei-Yi Kuo: Data analysis/interpretation, statistics, drafting article.

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Clinical Oral Investigations

Meng-Yao Chiu: data collection and analysis, drafting article. peri-implant marginal bone loss: a systematic review and meta-
Zhao-Zhao Chen: data analysis/interpretation, drafting article. analysis. J Periodontol 87:690–699
Hom-Lay Wang: data interpretation, drafting article, editing 13. Giannobile W, Jung R, Schwarz F, Groups of the 2nd Osteol-
articles. ogy Foundation Consensus Meeting (2018) Evidence-based
knowledge on the aesthetics and maintenance of peri-implant
Data availability  The data sets used and/or analyzed during the cur- soft tissues: Osteology Foundation Consensus Report Part
rent study are available from the corresponding author on reasonable 1-Effects of soft tissue augmentation procedures on the main-
request. tenance of peri-implant soft tissue health. Clin Oral Implants
Res 29:7–10
14. Berglundh T, Lindhe J (1996) Dimension of the periim-
Declarations  plant mucosa Biological width revisited. J Clin Periodontol
23:971–973
Ethics approval and consent to participate  This study was reviewed 15. Linkevicius T, Puisys A, Steigmann M, Vindasiute E, Link-
and approved by Chang Gung Medical Foundation Institutional Review eviciene L (2015) Influence of vertical soft tissue thickness on
Board (IRB No.: 202101533B0, 2021–08-27). crestal bone changes around implants with platform switch-
ing: a comparative clinical study. Clin Implant Dent Relat Res
Informed consent  Inform consent was approved and obtained from all 17:1228–1236
participants in present study. 16. Puisys A, Linkevicius T (2015) The influence of mucosal tissue
thickening on crestal bone stability around bone-level implants.
A prospective controlled clinical trial. Clin Oral Implants Res
Conflict of interest  The authors declare no competing interests.
26:123–129
17. Isler S, Uraz A, Kaymaz O, Cetiner D (2019) An evaluation of
the relationship between peri-implant soft tissue biotype and the
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