Marco Caneva Daniele Botticelli ` Paolo Vigano Fabrizio Morelli Massimiliano Rea Niklaus P.

Lang

Connective tissue grafts in conjunction with implants installed immediately into extraction sockets. An experimental study in dogs

Authors afliations: Marco Caneva, UNESP Universidade Estadual Paulista, Arac atuba Dental School, Aracatuba, Brazil Marco Caneva, Daniele Botticelli, ARDEC, Ariminum Odontologica, Rimini, Italy Faculdade de Odontologia de Arac atuba, UNESP Universidade Estadual Paulista, Paulista, Brazil ` , Fabrizio Morelli, Massimiliano Rea, Paolo Vigano Faculty of Dentistry, University of Medical Science, La Habana, Cuba Daniele Botticelli, Niklaus P. Lang, Prince Philip Dental Hospital, The University of Hong Kong, Hong Kong, China Corresponding author: Dott. Daniele Botticelli lio de Mesquita Universidade Estadual Paulista Ju Filho UNESP Campus de Arac atuba cio 1193, 16015-050 Arac Bonifa Rua Jose atuba (SP) Brazil Tel.: +55 02118 3636-3209 Fax: +55 02118 3636-3340 e-mail: daniele.botticelli@ardec.it

Key words: alveolar bone preservation, animal study, connective tissue, extraction socket,

graft, implant dentistry, regeneration

Abstract Aim: To evaluate the inuence of a sub-epithelial connective tissue graft placed at the buccal aspect of implants installed immediately after tooth extraction on the dimensional changes of hard and soft tissues. Materials and Methods: In six Labrador dogs a bilateral partial- thickness dissection was made buccal to the second mandibular premolar. At the lingual aspect, full-thickness aps were elevated. The teeth were extracted and implants installed immediately into the distal socket. A connective tissue graft was obtained from the palate and applied to the buccal aspect of the test sites, whereas contra-laterally, no graft was applied. The aps were sutured to allow a non-submerged installation. After 4 months of healing, the animals were sacriced, ground sections were obtained and histomorphometric analyses were performed. Results: After 4 months of healing, all implants were integrated (n = 6). Both at the test and at the control sites bone resorption occurred: 1.6 mm and 2.1 mm, respectively. The difference was not statistically signicant. The coronal aspect of the peri-implant soft tissue was wider and located more coronally at the test compared with the control sites. The differences were statistically signicant. Conclusions: The application of a connective tissue graft placed at the buccal aspect of the bony wall at implants installed immediately after tooth extraction yielded a minimal preservation of the hard tissues. The peri-implant mucosa, however, was signicantly thicker and more coronally positioned at the test compared with the control sites.

Date: Accepted 26 February 2012

To cite this article: ` P, Morelli F, Rea M, Lang NP. Caneva M, Botticelli D, Vigano Connective tissue grafts in conjunction with implants installed immediately into extraction sockets. An experimental study in dogs. Clin. Oral Impl. Res. 24, 2013, 5056 doi: 10.1111/j.1600-0501.2012.02450.x

Implant dentistry has constantly evolved towards a simplication of clinical procedures and shortened treatment times. In this respect, the propagation of e.g. apless surgery, immediate implant placement after tooth extraction and immediate implant restoration have to be mentioned (Belser et al. 2009). The installation of implants into sockets immediately after tooth extraction has been proven to be a reliable procedure (e.g. Quirynen et al. 2007; Lang et al. 2007; Botticelli et al. 2008; Chen & Buser 2009). However, this procedure is associated with the resorption of the buccal bony walls (e.g. Bot jo et al. 2005; ticelli et al. 2004, 2006; Arau Caneva et al. 2010a,b,c,d,e, 2011a,b, 2012; Vignoletti et al. 2009; Sanctis et al. 2009) resulting in jeopardized esthetic outcomes (Chen et al. 2007).

Several procedures have attempted to limit the resorption of the alveolar process after tooth extraction and immediate implant installation (Cornelini et al. 2004; Chen et al. 2007; Caneva et al. 2010a,b,c,d, 2011a,b, 2012). In general, improvement of the maintenance of the alveolar crest was reported at sites treated with various augmentation procedures compared with control sites where no adjunctive treatments were applied. Moreover, the use of connective grafts has been propagated to compensate for the ridge resorption after tooth extraction and immediate implant installation and thus, improved the esthetic outcomes (e.g. Edel 1995; Koury & Hoppe 2000; Bianchi & Sanlippo 2004; Covani et al. 2007; Kan et al. 2009). In an experiment in dogs (Fickl et al. 2008a,b), a connective tissue graft was used
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Caneva et al Connective tissue graft at implants

at extraction sockets in conjunction with bone llers. Improved outcomes were noted at sites treated with such grafts compared with the controls. In another experiment in dogs (Thoma et al. 2010), it was shown that connective tissue grafts were also effective to augment healed alveolar processes. Despite this large quantity of clinical studies on the use of connective tissue grafts at implants installed immediately after tooth extraction, only limited information is available from animal experiments. Hence, the aim of the present experiment was to evaluate the inuence of a buccal placement of a sub-epithelial connective tissue graft on the dimensional changes of hard and soft tissues at implants installed into sockets immediately after tooth extraction.

Material and methods

The research protocol was submitted to and approved by the local Ethical Committee for Animal Research (University of the State of Sa o Paolo, Brazil).
Clinical procedures

Umkirch, Germany). Subsequently, a titanium implant, 3.3 mm in diameter and 11.5 mm in length (Premium, Sweden & Martina, Due Carrare, Padova, Italy) with a rough surface (Zirti; zirconium sandblasted acid etched, Sweden & Martina, Due Carrare, Padova, Italy) was installed. The implant was positioned into the center of the alveolus (Fig. 1a), with the margin of the rough surface being placed ush with the alveolar buccal bony crest (Fig. 1b), so that the machined collar of the implant (0.8 mm in height) emerged above the buccal bony crest. A healing abutment was applied onto the implant. Before suturing, a connective tissue graft, about 1011 mm long, 67 mm wide and 3 4 mm thick, was harvested from the palate, in the area between the fourth premolar and rst molar (Fig. 2ad). The graft was applied at the buccal aspect of the experimental sites, in part on the bony plate and in part on the abutment (Fig. 3a). It was secured around the neck of the implant and to the underlined

(a)

Six Labrador dogs (each approximately 22 kg and with a mean age of 2 years) were used. During surgical procedures, the animals were pre-anesthetized with Acepran (0.05 mg/kg Univet-vetnil, Sa o Paulo, SP, Brazil), sedated with Zoletil 10 mg/kg (Virbac, Jurubatuba Santo-Amaro, SP, Brasil) and Xilazina lia, Sa (1 mg/kg Crista o Paulo, Brazil), complemented with Ketamine ( of dose of lia, Sa 10 mg/kg, Crista o Paulo, Brazil). During the entire surgery, the animals were kept with an intravenous infusion of sterile saline. On the left side of the mandible (test site), an intra-sulcular incision was performed at the level of P2 (second premolar). Then, a partial- thickness dissection was made buccally using a 15C blade (Hu-Friedy, Chicago, IL, USA) and leaving the underlying periosteum in place. At the lingual aspect, however, a full-thickness ap was elevated. The second premolar was hemisected and both roots removed. The bucco-lingual and mesiodistal dimensions at the coronal margin of the alveolus were measured using calipers (Castroviejo, KLS Martin Group, Umkirch, Germany), and the depth at the buccal and lingual aspects were measured using a UNC 15TM probe (Hu-Friedy, Chigaco, IL, USA), respectively. The width of the buccal and lingual bony walls was assessed at a 1 mm and 3 mm distance from the alveolar bony crest using Iwanson calipers (KLS Martin Group,
2012 John Wiley & Sons A/S

periosteum using sutures VicrylTM 4-0 and 6 0, respectively (Johnson & Johnson, Sa o Jose dos Campos, SP, Brazil). A light nger pressure was then applied to moist gauze over the grafted site for a minimum of 5 min to minimize blood clot formation between the graft and the underlying tissues. The aps were subsequently sutured to allow a nonsubmerged healing of the implants (Fig. 3b). In the right side of the mandible (control site), the same surgical procedures and measurements of the alveolus used in the contralateral side were adopted. However, no connective tissue grafts were applied. After the surgeries, the animals were given a vitamin compound (Potenay, Fort Dodge Animal Health, Campinas, Brazil; 1 ml/ 10 kg), anti-inammatory/analgesic drugs (Banamine, Schering-Plough, Rio de Janeiro, Brazil; 1 ml/10 kg) and antibiotics (Pentabiotico, Fort Dodge Animal Health, Campinas, Brazil; 0.1 ml/kg). The animals were kept in kennels and on concrete runs at the universitys eld laboratory with free access to water and feed of moistened balanced dogs chow. A daily inspection of the wounds for clinical signs of complications and healing abutment cleaning was performed. The animals were euthanized 4 months after the surgery applying an overdose of Thiopental (Cristalia Ltd, Campinas, Brazil).
Histological preparation

(b)

Individual bone blocks containing the implant and the surrounding soft and hard tissues were xed in 4% formaldehyde solution followed by dehydration in a series of graded ethanol solutions, and nally embedded in resin (LR White hard grade, London Resin Company Ltd, Berkshire, UK). The blocks were cut in a bucco-lingual plane using a diamond band saw tted in a precision slicing machine (Exakt, Apparatebau, Norderstedt, Germany) and then, reduced to a thickness of about 50 lm using a cutting grinding device (Exakt, Apparatebau). The histological slides were stained with toluidine blue and examined under a standard light microscope for histometric analysis.
Histological evaluation

Fig. 1. Clinical positioning of the implant within the distal extraction sockets of the second mandibular premolar. (a) Occlusal view identifying the central positioning of the implant. (b) Buccal view identifying the positioning of the rough/smooth surface limit of the implant ush with the alveolar crest.

In a Nikon Eclipse 50i microscope (Nikon Corporation, Tokio, Japan) at a magnication of 9100, the following landmarks were identied (Fig. 4): the shoulder of the implant (IS), the most coronal bone-to-implant contact (B), the top of the adjacent bony crest (C), the top of peri-implant mucosa (PM), the apical portion of the barrier (junctional) epithelium (aJE).

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(a)

(d)

(b)

(c)

Fig. 2. A connective tissue graft, about 1011 mm long (a), 67 mm wide (b) and 34 mm thick (c), was harvested from the palate, in the area between the fourth premolar and rst molar (d).

the vertical distance between PM and B (PM B) and PM and aJE (PMaJE); the horizontal width of the peri-implant mucosa 1 mm apically to PM and a the level of IS (WPM). The amount of bone-to-implant contact (BIC%) around the implant evaluated from B to the apical termination of the implant. The distance between the coronal margin of the rough surface (M) and B (MB), and the distance MC were calculated subtracting 0.8 mm of the machined implant collar from the measurements ISB and ISC, respectively. The distance aJEB and PMIS were also calculated. The percentage of mineralized bone determined in an area from the implant surface to a parallel line at a distance of about 1 mm was also assessed between B and the apical termination of the implant. Thus, a lattice was superimposed over this area.
Data analysis

(a)

Mean values and standard deviations as well as 25th, 50th (median), and 75th percentiles were calculated for each outcome variable. The primary variables for the hard tissues were MC and MB, whereas for the soft tissues, they were PMB, PMIS, and WPM. Differences between test and control sites were analyzed using Wilcoxon signed ranks test using PASW Statistics 19 (SPSS Inc. Chicago IL, USA). The level of signicance was set at a = 0.05.

Results
(b)
Clinical evaluation

Fig. 3. (a) The graft was applied at the buccal aspect of the experimental sites, in part on the bony plate and in part on the abutment. (b) The graft was secured around the neck of the implant and to the underlined periosteum using sutures VicrylTM 4-0 and 6-0, respectively.

Fig. 4. Diagram depicting the landmarks for the histological evaluation: (IS) the shoulder of the implant (B) the most coronal bone-to-implant contact (C) the top of the adjacent bony crest (PM) the top of peri-implant mucosa (aJE) the apical portion of the barrier (junctional) epithelium (M) the location of the coronal limit of rough/smooth implant surface, located 0.8 mm below IS.

During the healing period no major complications were observed. After 4 months of healing, all implants were clinically stable and did not display any signs of biological or technical complications. The coronal diameter and depth of the extraction sockets as well as the width of the buccal and lingual bony walls at 1 mm and 3 mm from the top of the alveolar crest before implant installation are reported in Table 1. All parameters were very similar on test and control sites, respectively, with no statistically signicant differences.
Histological evaluation

The following measurements of the hard and soft tissue dimensions were performed: (i) the vertical distance between IS and C (IS

C) and between IS and B (ISB); the remaining horizontal gap (GAP) between the implant surface and the socket bony wall;

During histological processing, no artifacts occurred, nor were there any tissue blocks destroyed. Hence, test and control sites yielded an n = 6. The implants appeared to be well integrated into mature bone (Fig. 5a and b). Both at the test and control sites, however, the
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Table 1. Coronal diameter and depth of extraction sockets and width of the buccal and lingual bone walls at 1 mm and 3 mm from the alveolar crest
Coronal diameter m-d Test Control 4.1 (0.5) 4.0 (0.3) b-l 3.6 (0.8) 3.6 (0.2) Depth b 9.3 (1.2) 9.2 (0.4) l 9.6 (0.7) 9.5 (0.5) Width at 1 mm b 0.7 (0.3) 0.6 (0.3) l 0.7 (0.5) 0.8 (0.3) Width at 3 mm b 1.8 (0.6) 1.5 (0.4) l 2.2 (0.5) 2.3 (0.5)

Mean values and standard deviations (SD) in millimeters. m-d = mesial-distal, b-l = buccal-lingual, b = buccal, l = lingual.

(a)

(b)

Fig. 5. Ground sections illustrating the healing after 4 months at the test (a) and control (b) sites. Toluidine blue stain; original magnication 916. The implants appeared to be well integrated into mature bone. Both at the test and control sites, however, the buccal bony walls were partly resorbed. The location of the periimplant mucosa in respect of the implant shoulder was more coronally located at the test compared with the control sites and the width of the mucosa 1 mm below the top of peri-implant mucosa was wider at the test compared with the control sites.

inammatory inltrates were found. The histological measurements are reported in Table 4. The location of PM in respect of B, as well as of the dimension of PMaJE and aJEB were similar between test and control sites. However, the location of PM in respect of the implant shoulder (IS) was more coronal located at the test compared with the control sites (P < 0.05). Moreover, the width of the mucosa 1 mm below PM was wider at the test compared with the control sites (P < 0.05).

Discussion
The present study evaluated the inuence of a sub-epithelial connective tissue graft placed at the buccal aspect of implants installed into sockets immediately after tooth extraction on the dimensional changes of hard and soft tissues. Although only minor and non-signicant changes were observed for the hard tissues, the peri-implant mucosal margin was signicantly more coronally located and the thickness of the mucosal cuff appeared signicantly increased at the test compared with the control sites. This, in turn, means that the connective tissue graft retained its volume at least in part. Considering the dimensions of the graft (thickness of 3 4 mm), the increase in volume of the test compared with the control sites has to be interpreted as being rather modest (0.4 mm) after 4 months of healing. It may be specu-

buccal bony walls were partly resorbed. The bony crest (C) as well as of the most coronal bone-to-implant contact (B) were more coronally located (difference 0.5 mm) at the test compared with the control sites (Table 2). However, the differences did not reach statistical signicance. A high degree of bone to implant contact was achieved at all sites (Table 2). Small residual defects were detectable around the marginal portion of the implant (Table 3). The soft tissues appeared to be well adapted around the neck of the implant and the healing abutment and no noticeable

lated that the dimensions of the mucosal thickness after 4 months may even be further reduced after longer observation periods. This would render the procedure to be of questionable value for improving esthetic outcomes. Moreover, the mucosal margin was located signicantly more coronal after 4 months of healing. Also, this coronal displacement (average 0.7 mm) must be interpreted with caution. Again, it cannot be excluded that further shrinkage after longer observation periods of the mucosal cuff will neutralize the originally encountered benets of connective tissue grafting. Hence, the indiscriminate recommendation of connective tissue grafts in conjunction with immediately installed implants into fresh extraction sockets has to be questioned. The positive dimensional changes that were only demonstrated after 4 months of healing, may be interpreted as moderate clinical success. Nevertheless, long-term clinical success regarding esthetic outcomes certainly would require much greater improvements in dimensions than those revealed by the present study. A recent systematic review on the dimensional changes of hard and soft tissues of the alveolar process following tooth extraction (Tan et al. 2012) demonstrated that despite the documented vertical loss of hard tissue dimensions of approximately 1.2 mm, the soft tissue contours remained essentially unchanged. This, in turn, means that the vertical thickness of the soft tissues of the edentulous area must increase if the hard tissue dimension is decreasing. One of the cited and analyzed studies (Schropp et al. 2003) yielded

Table 2. Histological measurements of the hard tissue after 4 months of healing

M-C mm b Test Mean and (SD) Percentiles 25th; 50th; 75th Control Mean and (SD) Percentiles 25th; 50th; 75th 1.6 (0.6) 1.6; 1.8; 1.9 2.1 (1.2) 1.4; 1.9; 2.1 l 0.8 (0.5) 0.5; 0.7; 0.9 0.8 (0.4) 0.6; 0.8; 0.9 M-B mm b 1.8 (0.4) 1.6; 1.8; 2.0 2.3 (1.1) 1.8; 2.0; 2.2 l 0.9 (0.5) 0.6; 0.7; 1.9 1.4 (1.2) 0.6; 0.9; 2.0 BIC% b 78.3 (16.8) 80.5; 83.5; 86.5 79.3 (12.7) 77.5; 82.5; 85.3 l 77.2 (18.1) 71.3; 81.0; 87.0 72.8 (8.2) 67.8; 72.5; 77.3 Mineralization% b 70.3 (6.8) 67.5; 72.0; 75.0 73.3 (9.9) 73.3; 77.5; 78.8 l 68.8 (11.0) 60.8; 74.0; 76.8 62.3 (20.3) 47.8; 59.5; 80.3

Mean values, standard deviations (SD) and 25th, 50th (median) and 75th percentiles. b = Buccal, l = Lingual, BIC = Bone-to-implant contact, M-C = Vertical distance from rough-smooth implant limit (M) to alveolar bony crest (C), M-B = Distance from rough-smooth implant limit (M) to the coronal end of osseointegration (B). P < 0.05 between control and test. 2012 John Wiley & Sons A/S

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Table 3. Histological measurements of the hard tissue after 4 months

C-B mm b Test Mean and (SD) Percentiles 25th; 50th; 75th Control Mean and (SD) Percentiles 25th; 50th; 75th 0.2 (0.3) 0.0; 0.0; 0.2 0.2 (0.3) 0.0; 0.0; 0.2 l 0.1 (0.2) 0.0; 0.1; 0.3 0.6 (0.9) 0.0; 0.0; 1.1 GAP mm b 0.1 (0.2) 0.0; 0.0; 0.2 0.1 (0.2) 0.0; 0.0; 0.1 l 0.1 (0.1) 0.0; 0.1; 0.2 0.4 (0.6) 0.0; 0.0; 0.6

Mean values, standard deviations (SD) and 25th, 50th (median), and 75th percentiles. b = Buccal, l = Lingual, C-B = Height of the remaining defect, GAP = Coronal width of the remaining defect. P < 0.05 between control and test.

even a slight increase in vertical buccal dimension from 0.10 mm after 3 months to 0.10 mm after 6 months and to 0.40 mm after 12 months. Therefore, in the present study, the documented differences between test and control sites may also be maintained long-term. In this latter case, the grafting procedure may, indeed, offer additional benets to the maintenance of the buccal soft tissue contour. Hence, long-term studies are desperately needed to answer this important clinical question. Despite the fact that the periosteum was left on the buccal wall of the extraction socket in the present study, buccal bony resorption occurred both at the test and at the control sites. This is in agreement with results of another experimental study in dogs that compared full-thickness ap and apless procedures for immediate implant installation after tooth extraction (Caneva et al. 2010a). No differences were found between the two techniques regarding buccal bony resorption. Different surgical procedures have been adopted for the restriction of the physiological alveolar bone resorption that occurs after tooth extraction and immediate implant installation, both in experimental (e.g. Cane jo va et al. 2010a,b,c,d,e, 2011a,b, 2012; Arau et al. 2010) and clinical studies (Cornelini et al. 2004; Chen et al. 2007). In particular,

in an experiment in dogs (Caneva et al. 2011a), the shrinkage of the alveolar crest process was evaluated at sites where immediate implant installation was performed after tooth extraction. One site was treated with deproteinized bovine bone mineral and a collagen membrane, whereas the control site was left untreated. The shrinkage after 4 months of healing was found at both sites, however, being larger at the control sites. In the present study, the use of the connective tissue grafts did not prevent bone resorption either. Similar techniques, aiming at protecting and/or augmenting sites where implants were installed into extraction sockets were adopted in several clinical studies (e.g. Edel 1995; Bianchi & Sanlippo 2004; Covani et al. 2007; Kan et al. 2009; Chen et al. 2009). The majority of these studies reported favorable outcomes using connective tissue grafts. In a clinical study on implants installed into extraction sockets (Bianchi & Sanlippo 2004), 116 patients were included. In ninety-six patients, a sub-epithelial connective tissue graft was placed to completely cover the sites whereas, at the contralateral site, the implants were installed in a conventional way. Better results over a 9-year period of follow-up were recorded at the treated sites in relation to esthetic outcomes and keratinized mucosal width. One clinical study (Chen et al. 2009), however, did not

report differences. Implants were installed into extraction sockets using a apless procedure. In the test sites, a connective tissue graft was positioned into the marginal gap between the healing cap and the buccal mucosa. The control site was left untreated. The margin of the mucosa at the buccal aspect was located slightly more coronally at the test site, the difference not being statistically signicant. It was shown, however, that the initial position of the implant in relation to the bucco-lingual plane was of importance for the nal outcome. In fact, the more buccally the implants were placed, the more recession occurred. The positioning of the buccal surface of the implant into the extraction socket in relation to the buccal bony wall affected the nal outcome on the hard tissue, as shown by experimental (Caneva et al. 2010d,e, 2012) and clinical studies (Sanz et al. 2010; Tomasi et al. 2010; Ferrus et al. 2010). The position of the hard tissues after healing will also inuence the position of the peri-implant soft tissues, as shown in a recent report (Caneva et al. 2012). The distal extraction socket of the fourth mandibular premolar was used for immediate implant installation. In the control site, a cylindric implant with a smaller diameter of the coronal portion of the alveolus was placed in the center of the socket. In the contralateral site, a conical implant of a similar dimension of the extraction socket was used so that the distance between the buccal surface of the implant and the outer contour of the buccal bony wall was reduced compared with the control site. After 4 months of healing, the vertical exposure of the buccal surface of the implant was higher at the test compared with the control sites. The soft tissue followed a similar pattern, so that the peri-implant mucosa resulted more apically positioned at the test compared with the control site. In the present study, the use of a connective graft had barely an effect on the hard tis-

Table 4. Histological measurements of soft tissue dimensions and location after 4 months of healing
PM-B b Test Mean and (SD) Percentiles 25th; 50th; 75th Control Mean and (SD) Percentiles 25th; 50th; 75th 3.2 (0.4) 2.9; 3.1; 3.5 3.0 (1.0) 2.3; 2.8; 3.4 l 2.2 (0.2) 2.0; 2.2; 2.4 2.6 (0.8) 2.0; 2.2; 2.9 PM-aJE b 2.1 (0.2) 2.0; 2.1; 2.1 1.9 (0.7) 1.3; 1.7; 2.3 l 1.6 (0.2) 1.5; 1.6; 1.7 1.6 (0.5) 1.2; 1.4; 1.9 aJE-B b 1.1 (0.3) 0.9; 1.2; 1.3 1.1 (0.3) 0.9; 1.1; 1.2 l 0.7 (0.2) 0.5; 0.7; 0.8 0.9 (0.3) 0.8; 0.8; 1.0 PM-IS* b 0.6 (0.6) 0.4; 0.5; 0.5 0.1 (0.6) 0.6; 0.3; 0.3 WPM* b 1.1 (0.4) 0.9; 1.0; 1.2 0.7 (0.1) 0.6; 0.7; 0.8

Mean values, standard deviations (SD) and 25th, 50th (median), and 75th percentiles in millimeters. PM = Peri-implant mucosa; (B) Most coronal bone-toimplant contact; aJE = apical termination of the barrier (junctional) epithelium. IS = Implant shoulder; WPM = width of the peri-implant mucosa 1 mm apically to PM; b = Buccal, l = Lingual. * P < 0.05 between test and control.

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sue preservation. However, the peri-implant mucosa resulted to be slightly wider and located more coronally at the test compared with the control sites. The favorable effect to augment the width of the soft tissue of alveolar crest was also documented in an experimental study in dogs after 1 and 3 months of healing (Thoma et al. 2009, 2010). Lateral bone defects of various dimensions were created in the mandible at the time of tooth extraction. After 2 months, the defects were treated using a collagen matrix or autogenous sub-epithelial connective tissue grafts, whereas one site was left without treatment (control site). Both treated sites shown a larger augmentation of the soft tissue compared with the control sites. However, after 3 months of healing the positive

outcomes were clearly reduced comparing with the 1-month data indicating some shrinkage of the tissues. The fact that in the present study the periimplant mucosa was wider and located more coronally in the sites treated with a connective tissue grafts compared with the control sites may help to improve the nal esthetics outcome (Cornelini et al. 2008; Kan et al. 2009; Tsuda et al. 2011) provided that the improved outcomes are preserved over time. In conclusion, the present study showed that the use of a connective tissue grafts placed on the buccal aspect of the bony wall at implants installed immediately after tooth extraction preserved the hard tissues to a very minor extent. The peri-implant mucosa, however, was thicker and more coronally

positioned at the test compared with the control sites after 4 months of healing.

Acknowledgements: This study has been supported by a grant from Sweden & Martina SRL, Due Carrare, Padova, Italy and by ARDEC, Ariminum Odontologica SRL, Rimini, Italy. The competent contributions of Professor Luiz Antonio Salata and Mr. Sebastia o Carlos Bianco (USP Faculty of Dentistry of Ribeira o Preto University of Sa o Paulo, Sa o Paulo, Brazil) in the histological processing are highly appreciated. All the authors declare to have no conict of interest with the materials used in the present study.

References
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