Hindawi Publishing Corporation

International Journal of Dentistry

Volume 2015, Article ID 740764, 9 pages
http://dx.doi.org/10.1155/2015/740764

Review Article
Soft Tissue Surgical Procedures for Optimizing
Anterior Implant Esthetics

Andreas L. Ioannou,1 Georgios A. Kotsakis,1 Michelle G. McHale,1 Donald E. Lareau,1,2

James E. Hinrichs,1 and Georgios E. Romanos3
1
Advanced Education Program in Periodontology, University of Minnesota, 515 Delaware Street SE, Minneapolis, MN 55455, USA
2
Private Practice, Edina, MN 55435, USA
3
Department of Periodontology, School of Dental Medicine, Stony Brook, NY 11794, USA

Correspondence should be addressed to Georgios A. Kotsakis; [email protected]

Received 15 August 2014; Revised 2 November 2014; Accepted 4 November 2014

Academic Editor: Francesco Carinci

Copyright © 2015 Andreas L. Ioannou et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Implant dentistry has been established as a predictable treatment with excellent clinical success to replace missing or nonrestorable
teeth. A successful esthetic implant reconstruction is predicated on two fundamental components: the reproduction of the natural
tooth characteristics on the implant crown and the establishment of soft tissue housing that will simulate a healthy periodontium. In
order for an implant to optimally rehabilitate esthetics, the peri-implant soft tissues must be preserved and/or augmented by means
of periodontal surgical procedures. Clinicians who practice implant dentistry should strive to achieve an esthetically successful
outcome beyond just osseointegration. Knowledge of a variety of available techniques and proper treatment planning enables the
clinician to meet the ever-increasing esthetic demands as requested by patients. The purpose of this paper is to enhance the implant
surgeon’s rationale and techniques beyond that of simply placing a functional restoration in an edentulous site to a level whereby
an implant-supported restoration is placed in reconstructed soft tissue, so the site is indiscernible from a natural tooth.

1. Introduction that the implant-supported restoration is indiscernible from a

natural tooth. This is especially important in areas of esthetic
Implant dentistry has been definitively established as a concern but not negligible in posterior sites where the added
predictable treatment modality for replacing missing or benefits of enhanced tissue contours cannot be overlooked.
nonrestorable teeth which yields excellent clinical success
rates. During the last decade, the focus of implant research
has shifted from the functional stability of the implant to 2. Indications
its esthetic integration in the smile. The esthetics of implant
restorations is dictated by two fundamental components: It may not be an overstatement that every surgical implant
the reproduction of the natural tooth characteristics on the procedure in the esthetic region constitutes an indication for
implant crown and the establishment of a soft tissue housing soft tissue grafting. The inevitable alteration of the alveolar
that will intimately embrace the crown. Therefore, the success ridge dimensions that follows a tooth extraction often results
of implant rehabilitation in the esthetic zone relies heavily in the placement of the implant in a site that has undergone
on the preservation or the augmentation of peri-implant soft a reduction in soft and hard tissue volume in comparison to
tissue by means of periodontal surgical procedures. its neighboring dentate sites [1–3]. This discrepancy is even
The aim of this paper is to enhance the implant surgeon’s more pronounced in single-implant sites where a concavity
armamentarium with rationale and techniques that extend forms between the edentulous site and the root prominences
beyond the placement of a functional restoration in an of the neighboring dentition. Subepithelial connective tissue
edentulous site to the restoration of soft tissue harmony so grafts (SCTG) or free gingival grafts (FGG) can be employed
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2 International Journal of Dentistry

Implants in the anterior maxilla: aesthetic challenges

(Ia) Need for significant

soft tissue contour
augmentation

(I) Adequate alveolar bone width

Placement of thick
(≥2 mm of buccal bone width
Preoperative SCTG during 1st stage
following restoratively driven implant
assessment of implant surgery
placement)
alveolar bone
Edentulous site width
in the anterior (Ib) Need for minor
maxilla (≤1 mm) soft tissue
contour augmentation

(II) Inadequate alveolar bone width

(less than 2 mm of buccal bone width Roll-flap technique or
following implant placement) “envelope” flap during
2nd stage surgery
Need for minor Need for significant
horizontal horizontal
augmentation augmentation

(IIa) Implant placement (IIb) Ridge augmentation

with simultaneous with GBR or block graft
guided bone prior to implant
regeneration (GBR)
placement
(Ia) and/or (Ib) for
optimal aesthetics

Figure 1: Implants in the anterior maxilla: a clinical decision-tree for overcoming aesthetic challenges.

in these cases to reconstruct the buccal dimensions of the lichen planus and pemphigoid, may pose a risk to the viability
site improving the tissue thickness. In addition, they create of autogenous connective tissue grafts placed on a recipient
the illusion of root prominence and increase the width of the bed that exhibits a pathologic healing response. There is no
crestal peri-implant mucosa in order to provide an emergence published evidence to either support or discourage the use of
profile for the restoration and enable the constructed site to soft tissue grafting techniques in such cases.
closely resemble a natural tooth. Smoking is another relative contraindication. It is well
The long-term stability of pink esthetics around dental established that a key determinant of soft tissue augmentation
implant prostheses has been strongly correlated with ade- success is revascularization of the graft. Nicotine contained
quate peri-implant soft tissue thickness, that is, a thick peri- in cigarettes causes vasoconstriction to the surgical site, often
implant biotype [4, 5]. When a thin biotype is diagnosed, a resulting in necrosis of the graft [11]. This nicotine-associated
SCTG or a FGG can be used to prevent potential long-term vasoconstriction, in combination with lack of adherence
recession of the facial mucosal margin or permeation of a gray of the fibroblasts [12] and alteration in immune response
color from the implant [6–8]. [13, 14], diminishes the likelihood for a successful outcome.
Factors that should be considered when evaluating the Preoperative assessment should attempt to identify such at-
need for soft tissue grafting include the level of clinical risk patients whereby the clinician must inform the patients
attachment on adjacent teeth to support papillary height, of the potential adverse effects associated with smoking. Local
the thickness of the coronal soft tissue margin to ensure a factors that may also limit patient selection include lack of
proper emergence profile, the thickness of labial soft tissue adequate tissue thickness at the palatal donor site or restricted
to simulate root eminence and prevent transillumination surgical access to intraoral donor sites such as the posterior
of underlying metallic structure, and the position of the of the hard palate or maxillary tuberosity.
mucogingival junction and amount of keratinized tissue so as
to blend harmoniously with that of the adjacent teeth [9, 10]
(Figure 1). 4. Treatment Planning and Timing for
Soft Tissue Grafting Procedures
3. Contraindications and Limitations
A thorough 3-dimensional preoperative evaluation of the
General and specific limitations apply to the use of a soft tis- edentulous site is critical to properly planning an implant
sue augmentation technique around dental implants. Certain case that will result in an esthetic outcome. Two diagnostic
medical conditions are considered general contraindications variables that should be taken into account preoperatively
to surgical intervention. Collagen disorders, such as erosive are bone and soft tissue volumes [15]. Long-term stability
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International Journal of Dentistry 3

of esthetics for an implant requires the implant to be 6. Subepithelial Connective Tissue Graft
surrounded by ∼1.8–2.0 mm of vital bone [16]. Lack of
adequate bone necessitates hard tissue grafting. Sites should SCTG procedures have been used successfully throughout
also be evaluated for soft tissue profile. A discrepancy of soft the years for the management of recession and soft tissue
tissue contours with adjacent teeth can be addressed with defects around natural teeth and for augmenting alveolar
augmentation. ridge contours [22, 23]. Some may argue that the tradi-
tional approaches for connective tissue grafting do not fare
Soft tissue augmentation can be performed simultane-
well when one attempts to graft and achieve cover of a
ously with implant placement and/or during the second
nonvital implant surface since the soft tissues around the
stage surgery, as will be described in the following technique
implant do not respond in the same manner as a vital
section. There is no evidence in the literature to support
tooth. Nonetheless, many of these procedures can be trans-
any advantage of simultaneous soft tissue augmentation over
lated directly to peri-implant soft tissue modification and
augmentation during second stage surgery. Both treatment
esthetic optimization. When indicated and properly utilized,
modalities have been shown to lead to better esthetics and
these surgical procedures can provide stable and significant
increased soft tissue thickness [17]. Even though both tech-
gains in soft tissue volume and contour that can contribute
niques yield favorable esthetics, the earlier the intervention
to the successful esthetic management of implant sites
is performed, the more opportunities the clinician has to
(Figure 3).
better control the final outcome. For instance, in a case
where the residual ridge has undergone significant atrophy,
the simultaneous soft tissue augmentation in conjunction
with first stage surgery will allow sufficient healing time 7. Technique for Soft Tissue Grafting during
to properly assess the site during second stage surgery. 1st Stage Implant Surgery
Consequently, additional soft tissue augmentation can be
performed simultaneously when uncovering the implant(s) Step 1: Treatment Planning. As in all surgical procedures,
in order to achieve a more ideal outcome. treatment planning is the cornerstone of success. Preop-
Soft tissue grafting can also be utilized as a “rescue erative identification of potential soft and/or hard tissue
procedure” to manage esthetic complications associated with deficiencies allows for the construction of an implant restora-
implants. Labial inclination of implants, buccal placement, or tion that will closely mimic that of the natural dentogin-
use of wide body contributes to a thin tissue biotype or thin gival complex and blend with the existing dentition in a
buccal bone that may lead to recessions [18], permeation of pleasing and esthetic fashion. A decision should be made
gray from the implant structure through the tissue, and expo- preoperatively whether soft tissue augmentation alone will be
sure of the titanium implant neck, all of which contribute to adequate to develop the desired treatment outcome or if bone
an inharmonious emergence profile of the implant-supported augmentation is also needed to achieve ideal implant position
restoration and an ersatz appearance of the patient’s smile and soft tissue esthetics.
[19, 20]. Additionally, soft tissue grafting following implant
placement can be used to correct complications associated Step 2: Graft Harvesting. The three most common intraoral
with soft tissue color mismatch to a level below clinical donor sites for harvesting connective tissue grafts are the
perception [21]. tuberosity [24], the single incision-deep palatal [25], and
the free gingival graft method-superficial palatal [26]. Donor
tissue for FGGs is routinely harvested from the hard palate
5. Free Gingival Graft since this area provides an ample surface area of keratinized
tissue. Nonetheless, relatively any intraoral site with adequate
The use of autogenous FGG in mucogingival surgeries pre- tissue thickness that displays keratinization, such as the
dates that of any other type of graft. FGGs are considered keratinized epithelium apical to the gingival crest of the
a reliable and efficacious approach for augmenting peri- maxillary molars, may be utilized to procure a FGG. The
implant soft tissue defects and are most often utilized to amount and quality of soft tissue available for harvesting
increase the amount of keratinized tissue around an implant. depend on donor site, that is, tuberosity versus palate. The
FGGs are the gold standard in cases when an increase in tuberosity generally provides enough tissue to cover a single
keratinized tissue is desired. or two implant site(s), while adequate tissue can be obtained
The most common donor site of a FGG is the highly ker- from the palate to cover an area two or three times wider than
atinized hard palate. That being said, the color and shade of that of the tuberosity, depending on the incision design. The
the augmented recipient site do not often blend naturally with quality of the tissue harvested from the tuberosity is superior
the adjacent soft tissues. This produces a nonesthetic result, to that obtained from the palate since the tuberosity offers
contradicting the initial purpose of the procedure. Even so, a graft composed of dense connective tissue, whereas the
a FGG to increase the keratinized tissue is recommended portion of the palatal connective tissue donor usually consists
for “rescue” procedures to cover exposed implant threads. of adipose tissue. Tissue obtained from the tuberosity usually
In addition, a FGG can be used for patients with low smile permits the harvesting of a significantly thicker graft than that
lines, when extensive soft tissue augmentation is needed, or obtained from the palate [27]. This broad piece of tuberosity
where the color of a FGG will not compromise the esthetic can be longitudinally sectioned to increase the amount of
appearance of the implant site (Figure 2). donor tissue.
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4 International Journal of Dentistry

(a) (b) (c)

(d) (e)

(f) (g)

(h) (i)

Figure 2: (a) Patient had previous bone grafting and numbers 8 and 9 implant placement. Note minimal keratinized attached gingiva over
grafted area of numbers 8 and 9 due to coronal advancement of the flap. (b) Note the deficient soft tissue profile following placement of a
provisional prosthesis with appropriate tooth emergence. (c) Donor site and graft procurement. (d) Collagen tape and cyanoacrylate to reduce
discomfort over donor site. (e) Graft secured and well adapted to recipient bed with multiple sutures. (f) Recipient site following healing. Note
the increase in height and thickness of the keratinized attached gingiva. (g) Numbers 8 and 9 implant sites prepared for second stage surgery.
(h) Recipient site after numbers 8 and 9 implant restorations, showing stable keratinized attached gingiva. (i) Lateral view of recipient site.
Note the thick buccal keratinized attached gingiva, establishing an esthetic emergence profile for the implant restorations.
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International Journal of Dentistry 5

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(j) (k) (l)

(m) (n) (o)

Figure 3: ((a), (b), and (c)) Patient presented for implant rehabilitation of number 7 lateral incisor. Not the high interdental smile line that
poses an esthetic challenge. Following ridge resorption, a concavity consistent with a Seibert Class I defect is seen in the edentulous site. ((d),
(e), and (f)) A block autograft was screwed in place to achieve horizontal ridge augmentation prior to implant placement. Particulated allograft
was utilized to graft the area between the block and the recipient bed. Note the significant enhancement of the tissue profile postsurgically.
((g), (h), and (i)) At four months after grafting the site was reentered and an implant was placed in the ideal 3-dimensional position. A
SCTG was utilized to replicate the root eminence and provide a natural emergence profile. ((j), (k), (l), and (m)) Postoperative healing view
shows excellent tissue contours at the site. A customized healing abutment was selected to mold the tissues after 2nd stage surgery. Note the
excellent positioning of the mucosal zenith at the time of provisionalization. ((n), (o)) Intraoral view of the final restorations in place. Crown
lengthening was performed on the adjacent teeth to address the patient’s overall esthetic demands. Note the excellent replication of gingival
characteristics on the peri-implant mucosa and the natural appearance of the restoration as it emerges from the augmented hard on soft
tissues at the site.
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6 International Journal of Dentistry

7.1. Harvesting from the Tuberosity. On the distal aspect of the for using this technique is that sounding reveals a limited
tuberosity a single, crestal beveled incision is made from the amount of connective tissue beneath the palatal mucosa.
mucogingival junction to the distofacial line angle of the most In contrast to the tuberosity area where connective tissue
distal tooth. The incision is located on the buccal aspect of the occupies the whole tissue volume underneath the epithelium,
ridge crest rather than midcrestal and connected to the distal here a limited amount of connective tissue exists between
surface of the most posterior tooth via a sulcular incision. the epithelium (superficial) and adipose tissue (deep). Conse-
Use of an Orban knife enhances the access to performing quently, use of the deep palatal harvest technique in patients
the sulcular incision. At this point, the palatal flap is raised with thin palatal mucosa as described before would not
until the distopalatal surface of the most distal tooth is procure an adequate thickness/volume of graft after removal
exposed. Then, a new blade (15c) is used to meticulously of the adipose tissue.
dissect the connective tissue from the flap and the underlying The superficial palatal harvest technique places a horizon-
periosteum. Tissue forceps and the suction tip should be tal anterior/posterior incision 3 mm away from the maxillary
delicately employed during procurement of the graft in order teeth, as described in the deep palatal harvest technique, as
to minimize excessive trauma to the donor tissue and prevent a partial-thickness incision of only 1.5–2 mm in thickness
inadvertent loss of the graft through the suction tip. Once and leaves the periosteum intact. A second anterior/posterior
the graft has been obtained, it is stored in saline to prevent horizontal partial-thickness incision is traced parallel to the
dehydration while the recipient bed is prepared. The donor first incision at a position closer to the midline. The distance
site flap is sutured closed at this time, preferably using between these two incisions is based upon the estimated
4-0 chromic gut and a continuous interlocking suturing amount of tissue graft required for grafting. The two horizon-
technique. tal incisions are connected via anterior and posterior vertical
partial-thickness incisions on the mesial and distal aspect of
7.2. Harvesting from Deep Palatal Tissue. If a deep palatal the graft. Either a sharpened gingivectomy knife (Kirkland
donor site is selected for harvesting the connective tissue knife) or a blade (15c) is utilized to separate the graft from the
graft, the donor site should be sounded to bone. This is underlying tissue for an ideal thickness of 1.5 mm to 2 mm.
performed to verify that the incision will not involve a Then the graft is placed on a moist, sterile surface whereby
periodontal pocket or bony dehiscence of a palatal root the superficial epithelium is removed by sharp dissection.
in order to avoid postoperative recession. A single, full- Adipose tissue is removed from the periosteal side of the
thickness horizontal incision is made at a right-angle to the graft with the aid of a fresh blade or LaGrange scissors
alveolar bone of the palatal keratinized tissue approximately until the harvested graft consists of only connective tissue
3 mm from the free gingival margin of the maxillary teeth. or/and epithelium. The tissue graft is used as a template
This first incision extends from the mesial aspect of the to trim a collagen biomaterial in the proper dimensions to
palatal root of the maxillary first molar as far anteriorly as cover the donor site wound. After adequate hemostasis has
needed for the appropriate amount of donor tissue required. been achieved at the denuded donor site by application of
A second incision is made parallel to the underlying bone gauze with digital pressure for 5–10 minutes, the collagen
so that a thin split-thickness flap is created to separate the biomaterial is placed over the wound and secured by the
underlying connective tissue from the superficial flap. When application of cyanoacrylate via pipette. Periodontal dressing
the desired volume of SCTG has been identified, the blade is may be utilized depending on the surgeon’s preference to
directed towards the bone at the edges of the graft so that the improve patient comfort.
SCTG is free except for its periosteal attachment. A Woodson Step 3: Preparation of the Recipient Site. The flap is designed
elevator is slid under the partial-thickness flap to separate to retain a band of keratinized mucosa on the buccal aspect
the graft from the underlying bone. The procured graft is of the flap whenever possible. Consequently, it may be
kept in saline-soaked gauzes until used. The palatal flap can advisable to place the initial incision slightly palatal rather
be closed with either single interrupted sutures, sling sutures than midcrestal. The crestal incision is extended as sulcular
around the maxillary teeth, or a combination of the above. It incisions onto the adjacent teeth or as papillae sparing vertical
is important that the clinician be familiar with the anatomy releasing incisions passing to the level of the mucogingival
of the palate in order to minimize the risk of hemorrhage junction. The length of each incision depends on the indi-
associated with traumatizing the major palatine artery during vidualized treatment plan. A full-thickness flap is raised to
harvesting of the graft. The arterial vascular trunk is typically allow access for surgical placement of the implant(s). The
located ∼12–17 mm from the CEJ of the posterior teeth in successful incorporation of a tissue graft does not depend
patients with an average or high palatal vault while the artery on the thickness of the incision since the combination of
is usually within 7 mm of the CEJ in patients with a shallow a tissue graft with either a full- or partial-thickness flap
palatal vault [28]. yields similar clinical results [29]. The recipient bed should
be kept well-hydrated with frequent irrigation throughout the
7.3. Harvesting from the Superficial Palatal Tissue. This tech- procedure.
nique is used for the harvesting of both the FGG and the In order to create a partial-thickness flap, the dissection
SCTG. This technique utilizes a very similar method to that should occur beyond the mucogingival junction, leaving a
of a FGG to harvest the SCTG, with the only difference being layer of approximately 2 to 3 mm of connective tissue and
that the epithelium is removed after harvesting. The rationale periosteum intact.
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International Journal of Dentistry 7

Step 4: Adaptation of the Soft Tissue Graft. Following place- the base of the labial pedicle. A horizontal mattress suture
ment of the implant(s), the procured graft is adapted to the with absorbable suturing material (5-0 chromic gut or vicryl)
area. The dimensions of the graft should be adequate to is initially passed from the base of the tunnel horizontally
provide soft tissue bulk at the level of the neck of the implant through the coronal margin of the deepithelized pedicle flap
to ensure an esthetic emergence profile for the restoration and back through the base of the tunnel in order to invert
as well as simulate a root prominence for the missing tooth. the deepithelized pedicle beneath the labial marginal gingiva.
The tissue graft should be trimmed to resemble a semicircular A knot is tied to secure the rolled pedicle flap beneath the
cone so that the apical aspect does not span to the proximal labial pouch and can be verified by slight blanching of the
surfaces of adjacent teeth. Such excessive soft tissue will create area. The patient is instructed to avoid mechanical trauma
a bulky visual effect rather than that resembling the natural to the area for the next couple of weeks and to use only a
gingival contours of adjacent teeth. There is no significant chlorhexidine rinse while the deepithelized pedicle flap heals.
clinical difference in regard to the orientation of the SCTG As in all implant cases, the construction of a well-contoured
during its placement into the recipient site. Based on studies restoration is critical to the maintenance of a desirable soft
on root coverage procedures, when the periosteal side of tissue profile and an acceptable esthetic outcome.
the graft opposes the flap rather than the recipient bed, the Other minimally invasive techniques for contour aug-
success of the outcome will not be compromised [30]. mentation are also available. One such example is the use of
a buccal “envelope” technique for sliding a connective tissue
Step 5: Suturing at the Recipient Bed. After trimming the graft graft on the labial aspect of the implant, as was originally
to the appropriate dimensions, the graft is secured in the described by Raetzke for use around teeth with mucogingival
recipient bed utilizing a palatal-locking suture technique. The defects [32]. In this technique, sharp dissection is employed
suture needle initially penetrates the palatal keratinized tissue to produce a partial-thickness “envelope” flap that extends
in a palatobuccal direction. The needle then passes through beyond the mucogingival junction on the facial of the implant
the mesial aspect of the graft employing a faciopalatal [33]. Subsequently, a SCTG is procured and slid in the buccal
direction. The sequence is repeated for the distal portion of envelope at the implant site. Lastly, sling sutures are utilized
the graft, and as the needle exits the palatal flap a second to secure the graft and coronally advance the flap [33].
time, a knot is placed on the palatal side. The apex of the Eghbali et al. have shown that a mean increase of 0.8 mm
graft is stabilized in the connective tissue at the base of the of mucosal thickness can be achieved with the use of this
flap so that the graft is stretched and well adapted onto technique, whose increase is stable for at least 9 months after
the recipient bed. It is emphasized that the graft should be surgery. Therefore this procedure could be also considered in
uniformly adapted and well secured on the recipient bed cases where minor buccal contour enhancement is indicated
to prevent disruption of plasmatic circulation and healing. [33].
The final adaptation should be verified with the aid of a
periodontal probe. Pressure is applied with moist gauze for
5 minutes. The flap is closed with single interrupted sutures 9. Conclusions
using a 4-0 or 5-0 suturing material. If passive closure cannot
Implant dentistry has been established as a predictable
be achieved, then horizontal vestibular releasing incisions
treatment modality with high clinical success rates. Esthetic
should be placed in the base of the labial flap with a fresh 15C
considerations for implant restorations and the role of sur-
blade until tension-free flap adaptation and closure can be
gical procedures in the creation and maintenance of peri-
accomplished.
implant soft tissue have been gaining interest over the years.
Clinicians who practice implant dentistry should attain more
8. Technique for Soft Tissue Grafting during than just implant osseointegration to achieve an esthetic,
2nd Stage Implant Surgery successful outcome. Knowledge of the variety of techniques
available and proper planning enable clinicians to meet
A broad variety of techniques have been proposed to augment patients’ increasing esthetic demands. However, the need for
the soft tissue profile of implants at second stage surgery. soft tissue augmentation procedures around dental implants
Ideally, second stage surgery should be a minimally invasive in the anterior esthetic zone remains a controversial topic and
procedure whereby minor revisions in soft tissue architecture lacks support from the literature. Long-term clinical trials are
can be accomplished to create a natural emergence profile for needed for better assessment of these surgical procedures.
the healing abutment and/or final restoration [31]. A rolled
pedicle flap can be used to augment the connective tissue that Conflict of Interests
covers the coronal portion of a submerged implant. Tissue
sounding is utilized to locate the palatal shoulder of the All of the authors declare that they have no conflict of
cover screw followed by an arcing crestal incision around interests regarding this paper.
the palatal aspect of the cover screw. Papillae sparing mesial
and distal vertical releasing incisions are placed, leaving the
labial pedicle flap intact. A blade (15c) is used to deepithelize
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