43 Soft tissue augmentation

(A) (B) (C)

Figure 43.1 Connective tissue graft. Thin biotype. (A) The deciduous tooth must be replaced by a dental implant. Note the thin biotype. (B) A connective
tissue graft is performed during implant surgery, to thicken the buccal mucosa. (C) Clinical view after 6 years.

(A) (B) (C)

Figure 43.2 Soft tissue ridge augmentation. (A) Horizontal and vertical defect. A 3-unit bridge supported by two dental implants (teeth 12 and 14) is
planned. (B) A connective tissue graft increases the soft tissue volume in the area of ridge defect to improve the shape of the pontic. (Tooth 13) (C) Clinical
view after 5 years showing the esthetic improvement due to the soft tissue augmentation.

Table 43.1 Guidelines for soft tissue augmentation procedures

Esthetic Keratinized augmentation Volume augmentation Morbidity

Apically positioned flap Moderate Moderate Low Low

Rotational flap High Moderate Low Low
Free gingival graft Low High Moderate High
Allogenic graft Moderate Moderate Moderate Low
Subepithelial connective tissue graft High Low High Moderate

Implant Dentistry at a Glance, First Edition. Jacques Malet, Francis Mora, Philippe Bouchard.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.

92 Chapter 43 Soft tissue augmentation

Rationale initial incision is displaced on the lingual/palatal side to manage a band
Peri-implant soft tissues differ from periodontal tissues in terms of of keratinized tissue on the vestibule. It is the technique of choice for
structure (more collagen fibers in a parallel arrangement) and defense non-esthetic areas. APF is performed when the keratinized mucosa
capacity (fewer cells) (see Chapter 2). The role of soft tissue in implant quantity is limited, at the time of implant placement (one-stage
success is still questionable. implant) or at second-stage surgery.
Although the presence of keratinized tissue is not essential for peri- Rotational flap (RF) techniques have been developed to augment
implant tissue health and implant survival (Wennstrom et al., 1994), soft tissue volume for esthetics (small defects) (Scharf & Tarnow,
it can certainly facilitate plaque control, which is a crucial prerequisite 1992), or to allow adequate closure after GBR procedures. Tissue
to long-term implant success. Moreover, soft tissue quality and quan- manipulation can be delicate and requires sufficient skill. The presence
tity around implants can have implications for esthetic results and soft of a pedicle allows good vascular nutrition of the displaced tissue.
tissue margin stability. Free gingival graft (FGG) allows a better keratinized tissue aug-
Soft tissue augmentation techniques aim to create an optimum soft mentation than all other procedures (Thoma et al., 2009). The esthetic
tissue environment around implants, to improve implant prognosis result is generally bad, and therefore this technique is not recom-
and/or prosthetic cosmetic integration. mended in esthetic areas.
However, it should be noted that the recommendations that follow Allogenic graft: freeze-dried skin allograft, acellular dermal matrix
are essentially based on clinicians’ opinions, as scientific data regard- graft, could be an alternative to free gingival graft for tissue stabiliza-
ing indications or technique selection (Klinge & Flemmig, 2009) are tion, with less morbidity. Clinical documentation is limited.
very limited in the literature. Subepithelial connective tissue graft (SECTG) is the technique of
choice when soft tissue volume augmentation is required (Thoma
Indications et al., 2009) especially in esthetic areas: thin biotype (Fig. 43.1),
The indications for soft tissue augmentation procedures can be divided extraction socket closure, ridge defects (Fig. 43.2). As for FGG, quan-
into two groups. tity is limited by anatomical parameters (donor site).
• Keratinized tissue augmentation is required when:
– a reduced keratinized tissue height (less than 2 mm) or width (less
than 1 mm) is associated with insufficient plaque control Timing for soft tissue augmentation
– a shallow vestibule prevents access to oral hygiene originally From a clinical point of view, evaluation of peri-implant mucosa
or after tissue displacement (bone regenerative procedures) should be done at each treatment step. The global approach is to
– soft tissue quantity is too small to assure covering of augmented prevent soft tissue loss and to limit the number of surgeries.
bone areas. Two-stage implants: decision making for soft tissue augmentation
• Soft tissue volume augmentation is performed in the following can be performed at second-stage surgery (except for esthetic cases).
situations: One-stage implants: soft tissue quality has to be adequate at the
– thin biotype when long-term soft tissue margin stability is required time of implant placement. In compromised cases, a soft tissue aug-
(esthetic) mentation must be performed 6 weeks before implant placement.
– ridge defects correction to improve pontic design for esthetic or Bone augmentation areas: a good soft tissue environment is required
plaque control (Seibert & Salama, 1996) for GBR and bone graft procedures. In cases of limited keratinized
– primary soft tissue closure on fresh extraction socket for ridge tissue, soft tissue augmentation can be performed 6 weeks before bone
preservation (see Chapter 32, Fig. 32.1) or covering of GBR material surgery, to improve soft tissue manipulation and site covering.
(Jung et al., 2004). However, the vascular supply can be decreased (scar tissue) by this
The decision to perform a soft tissue augmentation is based on risk first surgery, which is thus indicated only for compromised cases.
assessment (implant survival or esthetic) and the morbidity of the Demanding esthetic cases: as several soft tissue augmentations
surgery. These two parameters should be evaluated at the beginning could be indicated, they should be performed as soon as possible: at
of the treatment, as additional surgery is not always well received by the time of tooth extraction (FGG, SECTG), at the time of implant
the patient. placement (RF, SECTG), or at second-stage surgery (RF, SECTG).

Technical procedures (Table 43.1) Key points

All the techniques described below are derived from periodontal
• Keratinized mucosa around implants is not a prerequisite for the
plastic surgery (Bouchard et al., 2001).
survival of dental implants but may improve plaque control and
Technique selection depends on the quantity of residual keratinized
esthetics in some situations.
mucosa and the type of indication. The first choice is the less invasive
• The flap design should preserve the keratinized tissues around
one (low morbidity).
the implants.
Apically positioned flap (APF) is a simple technique that can be
• In an esthetic area SECTG is the gold standard.
applied during implant placement or at second-stage surgery. The

Soft tissue augmentation Chapter 43 93