Giovanni Zucchelli

Claudio Mazzotti
Ilham Mounssif
Monica Mele
Martina Stefanini
Lucio Montebugnoli

Authors affiliations:
Giovanni Zucchelli, Claudio Mazzotti, Ilham
Mounssif, Monica Mele, Martina Stefanini, Lucio
Montebugnoli, Department of Odontostomatology,
Bologna University, Bologna, Italy
Corresponding author:
Prof. Giovanni Zucchelli
Department of Odontostomatology
Bologna University
Via S. Vitale 59
40125 Bologna
Italy
Tel.: +390512088125
Fax: +39051225208
e-mail: giovanni.zucchelli@unibo.it

A novel surgicalprosthetic approach

for soft tissue dehiscence coverage
around single implant

Key words: clinical research, clinical trials, periodontology, soft tissue-implant interactions
Abstract
Objectives: The aim of the study was to evaluate soft-tissue coverage and patient aesthetic
satisfaction of a novel surgicalprosthetic approach to soft tissue dehiscence (STD) around single
endosseous implant.
Material and methods: Twenty patients with buccal soft tissues dehiscence around single implants
in the aesthetic area were consecutively enrolled. Treatment consisted in: removal of the implant
supported crown, reduction in the implant abutment, coronally advanced flap in combination with
connective tissue graft (CTG) and final restoration. The unrestored contralateral tooth normally
positioned without recession defect was used as a reference. The soft tissue coverage and patient
satisfaction were evaluated 1 year after the final restoration.
Results: One-year mean STD coverage was 96.3%, and complete coverage was achieved in 75% of
the treated sites. The increase (1.54 0.21 mm) in buccal soft tissue thickness (STT) at 1 year was
significantly correlated with CTG thickness at time of the surgery. The mean difference between
graft thickness and STT increase was 0.09 0.14 mm, corresponding to the 5.8% of the original
graft thickness. The aesthetic analysis showed a significant improvement between the baseline
(median, 3.8; 95% CI, 24) and the 1-year (median, 8.0; 95% CI, 810) visual analogue scale (VAS)
scores.
Conclusion: The results from the present study demonstrated that the proposed bilaminar
technique was effective in the coverage of buccal STD around single dental implant and the
suggested prostheticsurgical approach was aesthetically successful.

Date:
Accepted 18 July 2012
To cite this article:
Zucchelli G, Mazzotti C, Mounssif I, Mele M , Stefanini M,
Montebugnoli L. A novel surgicalprosthetic approach for soft
tissue dehiscence coverage around single implant.
Clin. Oral Impl. Res. 24, 2013, 957962
doi: 10.1111/clr.12003

2012 John Wiley & Sons A/S

The main goal in the implant rehabilitation

of the aesthetic area is patient satisfaction.
Similar to teeth, soft tissue stability is a significant factor to achieve aesthetic outcome.
A major concern is the appearance of soft tissue dehiscence (STD) in the facial aspect,
common finding following implant restorations (Adell et al. 1986; Bengazi et al. 1996;
Chang et al. 1999; Grunder 2000; Small &
Tarnow 2000; Kan et al. 2003; Cardaropoli
et al. 2006; Jemt et al. 2006; De Rouck et al.
2008; Evans & Chen 2008). Many factors
seem to influence the level of soft tissue
around dental implants, some of these have
been well studied, and others have not been
explored or are still controversial; the factors
considered in the literature (Sorni-Broker
et al. 2009; Nisapakultorn et al. 2010) are as
follows: (1) mucosal quality (keratinized vs.
non-keratinized), (2) mucosal attachment
(mobile vs. non-mobile), (3) mucosal thickness, (4) facial bone crest level and thickness,

(5) implant fixture angle, (6) interproximal

bone crest level, (7) level of first bone to
implant contact, (8) depth of implant platform, (9) micro and macrostructure of the
implant neck, (10) Implant-abutment and
prosthesis connection and (11) surgical technique.
As the teeth, surgical reduction in the periimplant STD may be indicated, particularly
in aesthetic area with a high lipline. Unlike
to teeth where the result after surgical root
coverage has been reported (Roccuzzo et al.
2002; Oates et al. 2003; Cairo et al. 2008;
Chambrone et al. 2009), STD coverage has
been much less studied. Some case reports
studies describe the use of the connective tissue graft (CTG) (Shibli et al. 2004; Lai et al.
2010) or the acellular dermal matrix graft
(Mareque-Bueno 2011) techniques to correct
soft tissue defects on implant sites. Only one
prospective cohort study (Burkhardt et al.
2008) tried to evaluate the outcome of STD

957

Zucchelli et al " A novel technique for soft tissue dehiscence coverage around implant

coverage around single implant restoration.

Coronal advanced flap (CAF) with CTG techniques were used to treat 10 patients and
evaluated the healing up to 6 months. After
1 month, the mean of STD coverage was
75%, 70% at 3 months and 66% at
6 months. The authors concluded that a clinically significant improvement of STD was
obtained with a combination of CAF and
CTG but complete recession coverage at
implant sites was not possible.
The aim of this prospective pilot study was
to apply a modified surgicalprosthetic
approach to STD around single implant restoration and to evaluate the soft-tissue coverage and patient aesthetic satisfaction 1 year
after the final restoration.

Material and methods

A total of 20 healthy patients were selected
from the University of Bologna, School of
Dentistry, Bologna, Italy, between February
2004 and February 2010. The subjects, 14
women and six men (2653 years of age),
showed soft tissues dehiscence at the buccal
aspect of an implant positioned in aesthetic
area (Fig. 1ac). Their chief complaint was
the unfavourable aesthetic appearances during the smile because of the exposure of
implant surface or disharmony in scalloping
of the marginal soft tissues. The patients
agreed to participate in this study and gave
their written informed consent. All participants met the following inclusion criteria: (1)
age ! 18 years, (2) periodontally and systemically healthy, (3) one single tooth replacement implant in aesthetic area (from first
right premolar to first left premolar) with STD
at the buccal aspect after more than 2 years of
loading, (4) absence of peri-implantitis signs
(5) no interproximal attachment loss for the
teeth neighbouring the implant (6) unrestored
contralateral tooth normally positioned without recession defect used as a reference
(Burkhardt et al. 2008), (7) no contraindications for periodontal surgery and not taking
medications known to interfere with periodontal and peri-implant tissue health or
healing and (8) smoking <10 cigarettes a day.
Study design

This was a prospective pilot study with the

aim to evaluate the outcome of STD coverage
around implants 1 year after the final prosthetic restorations. The study protocol
involved a screening appointment to verify
eligibility of the patients, followed by initial
therapy to establish optimal plaque control

958 |

Clin. Oral Impl. Res. 24, 2013 / 957962

(a)

(b)

(d)

(e)

(c)

Fig. 1. (a) Upper left first premolar showed a buccal soft tissue deishence. (b) Lateral view. (c) Periapical radiograph
showing no signs of perimplantitis. (d) One month before surgery the implant supported crown was removed and
the underlying abutment was reduced and polished in order to create an adequate finishing line. (e) A temporary restoration was performed with the same shape and level of the occlusal plane of the contralateral homologous tooth
used as a reference.

and gingival/mucosal health conditions. Clinical measurements were taken at baseline

and 1 year after final restoration, and at the
same appointments, an aesthetic evaluation
was performed by patients.
Initial therapy

Following the screening examination, all subjects received a session of prophylaxis to

remove microbial deposits, including instruction in proper oral hygiene measures, scaling
and professional tooth cleaning with the use
of a rubber cup and a low-abrasive polishing
paste. The patients were instructed to use a
coronally directed roll technique for the
implant sites to minimize toothbrushing
trauma to the marginal soft tissues. Surgical
treatment of the STD was not scheduled
until the patient could demonstrate an adequate standard of plaque control.
Provisional prosthetic phase

The implant crown restoration was removed

1 month before surgery, and the underlying
abutment was milled and polished, if necessary, to create an adequate finishing line
(Fig. 1d). This permitted to use the already
present as temporary abutment to create a
provisional restorative crown (Fig. 1e) and
minimize the influence of the abutment margin on soft tissue healing after the surgery.
Stent preparation

Two weeks before the surgery (baseline), a

stent was fabricated using resin material1
1
Pattern Resin; CG Italy, San Giuliano Milanese, Italia.

directly in the mouth. The stent was leaning

on neighbouring elements without interfering
with the prosthetic element of the implant.
A reference point (slot) was impressed on the
stent at the mid-buccal area of the implant
site to allow reproducible periodontal probe
positioning. The apical margin of the stent
was at the same level of the occlusal surface
of the homologous contralateral tooth and
served as a measurement reference point
(Cortellini et al. 2009).
Clinical measurements

Full-mouth and local plaque scores were

recorded at baseline and 1 year after final restoration as the percentage of total surfaces
(four aspects per tooth) that revealed the presence of plaque (OLeary et al. 1972). Bleeding
on probing was assessed dichotomously at a
force of 0.3 N with the manual pressure sensitive probe (PCP-UNC 15)2, equipped with a
Brodontic spring device3. Full-mouth and
local bleeding scores were recorded as the
percentage of total surfaces (four aspects per
tooth) that bled on probing. The length of the
clinical crown of the contralateral tooth
(CCL) was measured with the manual probe
from the tip of the tooth to the gingival margin at the baseline.
The following clinical measurements were
taken 2 weeks before surgery (baseline) and
1 year after final restoration at the mid-buccal aspect of the study implant:
2
PCP-UNC 15 probe tip; Hu Friedy, Chicago,
IL, USA.
3
Brodontic Dentramar, Waalwijk, the Netherlands.

2012 John Wiley & Sons A/S

Zucchelli et al " A novel technique for soft tissue dehiscence coverage around implant

Peri-implant probing depth (PPD), measured from the soft tissue margin (STM)
to the bottom of peri-implant sulcus;
Clinical attachment level (CAL), measured from the stent reference point
(StRP) to the bottom of peri-implant sulcus;
Soft tissue dehiscence, measured by subtracting CCL at the distance from StRP
to the STM.
Height of keratinized tissue (KTH), measured from STM and the mucogingival
junction identified by means of Lugol
staining;
Soft tissue thickness (STT), determined
1.5 mm apical to the STM with a short
needle for anaesthesia and a 3-mm-diameter
silicon disk stop. The needle was inserted
perpendicular to the mucosal surface,
through the soft tissues with light pressure until a hard surface was felt. The silicon disk stop was then placed in tight
contact with the soft tissue surface with
the coronal border overlapping the STM.
As the needle was located in the centre of
the silicon disk, measurement of STT
was performed 1.5 mm apical from the
STM. Once in the correct position, the
disk was fixed with a drop of cyanocrylic
adhesive; after careful removal of the needle, the penetration depth was measured
with a caliper accurate to the nearest
0.1 mm (Paolantonio et al. 2002; da Silva
et al. 2004; Joly et al. 2007; Zucchelli
et al. 2010).

All measurements (except STT) were performed by means manual probe and were
rounded up to the nearest 0.5 mm.
Patient aesthetics evaluation

Patient satisfaction with aesthetics was

evaluated with a questionnaire at baseline
and 1-year follow-up visit based on a visual
analogue scale (VAS) (Cortellini et al. 2001,
2009). Patients were asked to select among
100 scores (0 indicating very bad, 50 indicating average, 100 indicating excellent) their
personal aesthetic evaluation.
Surgical techniques

All STD defects were treated with coronally

advanced flap (CAF) and CTG (Zucchelli
et al. 2003) (Fig. 2f). The flap was elevated
split-thickness, and all muscle insertions
were eliminated so as to permit its coronal
displacement. The exposed implant surface,
if present, was mechanically treated with the
use of diamond burs and then polished with
rubber cups. The facial and occlusal portions
2012 John Wiley & Sons A/S

(g)

(f)

(h)

(k)

(j)

Fig. 2. (f) The graft was positioned to cover the implant-abutment surface and secured at the base of the anatomic
papillae with two resorbable interrupted sutures and in the apical portion with two single sutures anchored to the
periosteum. (g) Occlusal view: note the disepithelisation extended in the occlusal and palatal direction. (h) Lateral
view showing the connective tissue graft (CTG) thickness. (j) The covering flap was sutured with interrupted
sutures in the releasing incisions. The coronal sling suture permitted to stabilize the surgical papillae over the interproximal connective tissue bed and allowed for a precise adaptation of the flap margin over the underlying implant
abutment without tensions. (k) Lateral view of the coronally sutured flap.

of the anatomical papillae were de-epithelized

to create connective tissue beds to which the
surgical papillae of the coronally advanced
flap was secured at time of suturing. The
CTG was harvested from the palate and
derived from the de-epithelization with the
blade of a free gingival graft (Zucchelli et al.
2010). The thickness of the free gingival graft
was about 2 mm. The mesio-distal length
was 6 mm greater than the width of the
dehiscence defect and the apico-coronal
dimension was 3 mm more to the depth of
the bone dehiscence (measured from the CCL
reference point to the buccal bone crest). The
graft was positioned to cover the implantabutment surface from the CCL reference
point and secured at the base of the anatomical papillae with two resorbable interrupted
sutures and in the apical portion with two
single sutures anchored to the periosteum
(Fig. 2fh). Flap mobilization was considered
adequate when the STM was able to passively reach a level coronal to the CTG. The
flap was sutured in a coronal position to
cover the CTG without tension (Fig. 2j, k).
All the sutures were performed in 6-0
Vicryl4. At the end of the surgery, the provisional crown was reduced to avoid contact
with the soft tissue and was provisionally
cemented (Fig. 3ln).

Patients were prescribed antibiotics5 (amoxicillin plus clavulanic acid 1 g/die) starting
1 h before surgery (2 g) and for further 6 days.
One tablet of anti-inflammatory drug (ibuprophene 600 mg) was given to the patients
30 min prior to surgery and 1 more, 6 h after
the intervention. Patients were instructed
not to brush teeth and implant in the treated
area, but to rinse for 1 min with a 0.12%
chlorhexidine solution three times a day.
Fourteen days after the surgical treatment,
the sutures were removed. Plaque control in
the surgically treated area was maintained by
rinsing with chlorhexidine for an additional
2 weeks. After this period, patients were
again instructed to mechanical tooth cleaning of the treated area using an ultrasoft
toothbrush and a roll technique for 1 month.
During this period, the chlorhexidine rinse
was used twice a day. Then, patients were
instructed to use a soft toothbrush and rinse
with chlorhexidine once a day for another
month. When chlorhexidine was discontinued full mechanical interproximal cleaning
in the surgically area was reinstituted. The
patient was recalled for prophylaxis every
2 weeks after suture removal for the first
2 months and, subsequently, once a month
until the final restoration.

4
Vicryl; Johonson & Johonson
Belgium).

5
Augmentin, Smith Klein Beecham, S.p.a.,
Milan.

(Woluwe,

Post-surgical infection control

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Clin. Oral Impl. Res. 24, 2013 / 957962

Zucchelli et al " A novel technique for soft tissue dehiscence coverage around implant

(l)

(n)

(p)

(o)

Fig. 3. (l) The temporary crown was reduced in order to

avoid contact with the soft tissue and was provisionally
cemented. (n) Lateral view. (o) One-year after final prosthetic phase the implant showed a complete coverage of
soft tissue dehiscence and a good aesthetic appearance.
(p) Lateral view showing the increase in buccal soft tissue thickness.

Final prosthetic phase

Eight months after surgical procedures, a

definitive impression was made, and the
resulting cast was used for abutment selection and crown design. The final shape of the
abutment was selected according to the axis
of the implant and the soft tissue around it.
A metal-ceramic crown was performed as the
definitive restoration (Fig. 3o, p). No interference with the stent was present at the time
of final delivery.
Data analysis

A Statistical Application Software6 (1) was

used for the statistical analysis.
Descriptive statistics were expressed as
mean (SD) and as median (95% CI).
Wilcoxon signed-rank test was applied to
compare baseline and 1-year clinical parameters: STD, CAL, PPD, KTH and STT.
A simple regression procedure was applied
to describe the relationship between STT
increase as a dependent variable and GT.

Table 1 summarize the baseline and 1-year

data for each parameter considered in the
study.
The differences between baseline and
1-year values and the statistically significance are also reported.
The mean of STD was 2.72 0.68 mm at
baseline and 0.10 0.44 mm 1 year after
the
final
restoration.
The
difference
(2.62 0.81 mm) was statistically significant
and corresponded to a mean STD coverage of
96.3%. Complete coverage was observed in
75% of the treated sites.
Baseline and 1-year CAL were 16.02
1.63 mm and 13 1.52 mm, respectively.
The CAL gain (3.02 1.06 mm) was statistically significant (P < 0.01).
Baseline PPD was 1.87 0.51 mm while
1-year PPD was 2.27 0.69 mm. This increase
was statistically significant (P < 0.05).
Baseline KTH was 1.72 0.61 mm while
1-year KTH after was 2.30 0.52 mm. KTH
increase (0.57 0.41 mm) was statistically
significant (P < 0.01).
Mean STT measured at baseline was
0.92 0.27 mm. The thickness of the deepithelized gingival graft (GT) was 1.64
0.18 mm. One-year STT was 2.50 0.39 mm.
Mean increase in STT (1.58 0.21 mm) was
statistically significant (P < 0.01). The mean
difference between GT and STT increase was
0.09 0.14 mm, corresponding to the 5.8% of
the original graft thickness. In four patients,
the STT increase was greater than the GT (difference 0.06 0.05 mm), and in two patients,
the STT increase was equal to the GT.
The results of the simple regression
showed a significant linear relationship
(F = 22.7; P < 0.01 with a correlation coefficient of 0.74) between STT increase and GT;
one observation had Studentized residuals >3;
its removal increases the significance of the
relationship (F = 51.6 with a correlation coefficient of 0.87).
The VAS analysis showed a significant
difference (W = 400.0; P < 0.01) between
baseline VAS (median, 3.8; 95% CI, 24)
and 1-year VAS (median, 8.0; 95% CI,
810) scores.

Discussion
The results from the present study demonstrated that the proposed bilaminar technique
was highly effective in the treatment of buccal STD around single dental implant. A statistically and clinically significant shortening
of the implant supported clinical crown was
achieved in all treated cases and complete
coverage (at the level of the gingival marginal
of the contralateral healthy natural tooth)
was achieved in the majority (75%) of the
treated defects. Furthermore, a statistically
significant improvement in the subjective
patients aesthetic evaluation was accomplished when comparing the baseline and
1-year aesthetic VAS scores.
This successful outcome were similar to
those reported for the treatment of I and II
Miller class gingival recession with the bilaminar root coverage technique (Cairo et al.
2008; Chambrone et al. 2009). Conversely,
present study outcome were more successful
with respect to those reported in a very similar 6-month study on the treatment of buccal
STD around dental implant (Burkhardt et al.
2008). In this study, not only lower percentage of mean of STD coverage was achieved
with the surgery but also the 1-month outcome got worse in the following 5 months.
According to the authors, complete recession
coverage was not achievable around dental
implant. Comparison between different studies can only be speculative in nature; however, the different outcomes can be explained
by differences in the surgical and prosthetic
managements of the clinical cases treated in
the present study. From a prosthetic standpoint, the removal of the implant crown
together with the reduction in the implant
abutment provided greater interdental connective tissue beds, between the implant
abutment and the adjacent teeth, for the graft
and for the surgical papillae of the covering
flap. The absence of the prosthetic crown
during the surgery, permitted to extend the
disepitelization of the interdental soft tissue
in the occlusal and palatal direction. In

Results
Table 1. Clinical parameter: median (95% CI for median)

Following the initial oral hygiene phase and

at the post-treatment examinations, all subjects showed a full-mouth plaque score and
bleeding score <15%, indicating good standard of supragingival plaque control during
the study period.
6
SAS, version 6.09; SAS Institute, Cary, NC,
USA.

960 |

Clin. Oral Impl. Res. 24, 2013 / 957962

STD
PPD
CAL
KTH
STT

Baseline (median;
95% CI)

1 year (median;
95% CI)

Wilcoxon W test

Mean differences
(mm) SD

3.0; 2.253.0
2.0; 2.02.5
15.75; 15.2516.75
1.75; 1.252.0
0.9, .751.1

0; 00
2.0; 1.752.0
13.0; 12.013.75
2.0; 2.02.75
2.45; 2.252.5

400; P < 0.01

265.5; P < 0.05
365.5; P < 0.01
298.0; P < 0.01
400.0; P < 0.01

2.62
0.40
3.02
0.57
1.54

0.81
0.73
1.06
0.41
0.21

CAL, clinical attachment level; KTH, height of keratinized tissue; PPD, peri-implant probing depth;
STD, soft tissue dehiscence; STT, soft tissue thickness.
2012 John Wiley & Sons A/S

Zucchelli et al " A novel technique for soft tissue dehiscence coverage around implant

particular, the reduction in the abutment,

performed 1 month before the surgery, by
eliminating abutment shoulders or chamfers,
allowed for the interdental soft tissue to
occupy the space previously occupied by the
metal. This might have increased the width
and the volume of the interdental soft tissue
at time of the surgery and improved vascular
exchange with the graft and the surgical
papillae of the covering flap. In addiction, it
cannot be excluded that milling the implant
abutment might have reduced implant proclination and permitted a better adaptation
between the graft and the smoothed underlying abutment buccal surface (Nisapakultorn
et al. 2010). Both these factors might have
contributed to achieve better coverage of the
buccal STD. Finally, shortening the temporary crown at the end of the surgery might
have allowed for an undisturbed healing
without the interference of the preoperative
crownabutment interface.
Differences in the surgical technique could
also explain the improved outcome of the
present study. A thick CTG was used in both
studies (Burkhardt et al. 2008), but different
harvesting techniques were used. In the
Burkhard et al.s study, a CTG, harvested
with a single incision harvesting techniques,
was used (Hurzeler & Weng 1999; Lorenzana
& Allen 2000); conversely, a free gingival
graft, subsequently disepithelized with the
blade was utilized in the present study. Some
advantages derives from this choice: the connective tissue used for the graft is that one
closer to the epithelium that is more dense
and stable and thus less prone to contraction,
with respect to the connective tissue closer

to the bone that is more rich of fatty and

glandular tissue (Zucchelli et al. 2010). The
difference in the quality of the CTG could be
particularly significant when thick graft, like
those utilized in the present study, are harvested; in a thick graft, the proportion of
glandular and fatty tissue included in the
graft increases with respect to the denser
connective tissue close to the epithelium
that is left in the primary flap of the single
incision technique.
The good quality of the CTG used in the
present study might explain the positive correlation between the graft thickness at time
of the surgery, and the 1-year increase in the
buccal STT achieved with the surgery. Furthermore, in the present study, the mean
increase in buccal STT at 1 year was similar
to the mean graft thickness at time of suture.
It can be speculated that almost all the thickness of the graft became buccal gingival
thickness at 1 year. This is in accordance
with previous data on disepithelized free gingival graft use for root coverage (Zucchelli
et al. 2010). In the entire population of the
present study, only a very limited percentage
(around 5.8% in mean values) of graft thickness did not become STT; indeed, in six
patients the graft thickness was equal or
lower than the 1-year increase in buccal STT.
These data confirm the stability of the subepithelial palatal connective tissue used for
grafting purpose.
Another peculiarity of the presented surgical technique was the disepithelization of the
interdental soft tissue, between the reduced
abutment surface and the adjacent teeth, in
the occlusal and palatal directions that

allowed for a more coronal placement of the

CTG and for a greater coronal advancement
of the covering flap. This might have contributed to improve soft-tissue coverage outcome
(Pini Prato et al. 2005) and permitted to
maintain the graft covered by the primary
flap. The lack of graft exposure might contribute to explain the favourable aesthetic
outcome reported by the patients. From the
present study data, it cannot be excluded that
also the replacement of the final implant supported crown might have had a critical role
in the improvement of the aesthetic VAS
scores reported in the present study.

Conclusions
Within the limits of the present pilot study,
some conclusions can be drawn:

The utilized bilaminar technique was

effective in achieving coverage of the
STD around single dental implant.
Complete coverage, at the level of the
homologous contralateral tooth, was
achieved in the 75% of the treated
defects.
The utilized surgical technique together
with the replacement of the implant supported crown permitted to achieve a significant improvement in the patient
aesthetic evaluation.

Further controlled multicentre clinical trials are needed to confirm the encouraging
results of the present pilot study.

References
Adell, R., Lekholm, U., Rockler, B., Branemark,
P.I., Lindhe, J., Eriksson, B. & Sbordone, L. (1986)
Marginal tissue reactions at osseointegrated titanium fixtures (i). A 3-year longitudinal prospective study. International Journal of Oral and
Maxillofacial Surgery 15: 3952.
Bengazi, F., Wennstrom, J.L. & Lekholm, U. (1996)
Recession of the soft tissue margin at oral
implants. A 2-year longitudinal prospective study.
Clinical Oral Implants Research 7: 303310.
Burkhardt, R., Joss, A. & Lang, N.P. (2008) Soft tissue dehiscence coverage around endosseous
implants: a prospective cohort study. Clinical
Oral Implants Research 19: 451457.
Cairo, F., Pagliaro, U. & Nieri, M. (2008) Treatment
of gingival recession with coronally advanced flap
procedures: a systematic review. Journal of Clinical Periodontology 35: 136162.
Cardaropoli, G., Lekholm, U. & Wennstrom, J.L.
(2006) Tissue alterations at implant-supported
single-tooth replacements: a 1-year prospective

2012 John Wiley & Sons A/S

clinical study. Clinical Oral Implants Research

17: 165171.
Chambrone, L., Sukekava, F., Araujo, M.G., Pustiglioni, F.E., Chambrone, L.A. & Lima, L.A. (2009)
Root coverage procedures for the treatment of localised recession-type defects. The Cochrane Database of Systematic Reviews Issue 2: CD007161.
Review.
Chang, M., Wennstrom, J.L., Odman, P. & Andersson, B. (1999) Implant supported single-tooth
replacements compared to contralateral natural
teeth. Crown and soft tissue dimensions. Clinical
Oral Implants Research 10: 185194.
Cortellini, P., Tonetti, M., Baldi, C., Francetti, L.,
Rasperini, G., Rotundo, R., Nieri, M., Franceschi,
D., Labriola, A. & Prato, G.P. (2009) Does placement of a connective tissue graft improve the outcomes of coronally advanced flap for coverage of
single gingival recessions in upper anterior teeth?
A multi-centre, randomized, double-blind, clinical
trial. Journal of Clinical Periodontology 36: 6879.

Cortellini, P., Tonetti, M.S., Lang, N.P., Suvan, J.E.,

Zucchelli, G., Vangsted, T., Silvestri, M., Rossi,
R., McClain, P., Fonzar, A., Dubravec, D. &
Adriaens, P. (2001) The simplified papilla preservation flap in the regenerative treatment of deep
intrabony defects: clinical outcomes and postoperative morbidity. Journal of Periodontology 72:
17021712.
De Rouck, T., Collys, K. & Cosyn, J. (2008) Immediate single-tooth implants in the anterior maxilla: a 1-year case cohort study on hard and soft
tissue response. Journal of Clinical Periodontology 35: 649657.
Evans, C.D. & Chen, S.T. (2008) Esthetic outcomes
of immediate implant placements. Clinical Oral
Implants Research 19: 7380.
Grunder, U. (2000) Stability of the mucosal topography around single-tooth implants and adjacent teeth: 1-year results. The International
Journal of Periodontics & Restorative Dentistry
20: 1117.

961 |

Clin. Oral Impl. Res. 24, 2013 / 957962

Zucchelli et al " A novel technique for soft tissue dehiscence coverage around implant
Hurzeler, M.B. & Weng, D. (1999) A single-incision
technique to harvest subepithelial connective tissue grafts from the palate. The International Journal of Periodontics & Restorative Dentistry 19:
279287.
Jemt, T., Ahlberg, G., Henriksson, K. & Bondevik,
O. (2006) Changes of anterior clinical crown
height in patients provided with single-implant
restorations after more than 15 years of followup. The International Journal of Prosthodontics
19: 455461.
Joly, J.C., Carvalho, A.M., da Silva, R.C., Ciotti,
D.L. & Cury, P.R. (2007) Root coverage in isolated gingival recessions using autograft versus
allograft: a pilot study. Journal of Periodontology
78: 10171022.
Kan, J.Y., Rungcharassaeng, K. & Lozada, J. (2003)
Immediate placement and provisionalization of
maxillary anterior single implants: 1-year prospective study. International Journal of Oral and
Maxillofacial Implants 18: 3139.
Lai, Y.L., Chen, H.L., Chang, L.Y. & Lee, S.Y.
(2010) Resubmergence technique for the management of soft tissue recession around an implant:
case report. International Journal of Oral and
Maxillofacial Implants 25: 201204.
Lorenzana, E.R. & Allen, E.P. (2000) The singleincision palatal harvest technique: a strategy for
esthetics and patient comfort. The International
Journal of Periodontics & Restorative Dentistry
20: 297305.
Mareque-Bueno, S. (2011) A novel surgical procedure for coronally repositioning of the buccal

962 |

Clin. Oral Impl. Res. 24, 2013 / 957962

implant
mucosa
using
acellular
dermal
matrix: a case report. Journal of Periodontology
82: 151156.
Nisapakultorn, K., Suphanantachat, S., Silkosessak,
O. & Rattanamongkolgul, S. (2010) Factors affecting soft tissue level around anterior maxillary single-tooth implants. Clinical Oral Implants
Research 21: 662670.
Oates, T.W., Robinson, M. & Gunsolley, J.C. (2003)
Surgical therapies for the treatment of gingival
recession. A systematic review. Annals of Periodontology 8: 303320.
OLeary, T.J., Drake, R.B. & Naylor, J.E. (1972) The
plaque control record. Journal of Periodontology
43: 38.
Paolantonio, M., Dolci, M., Esposito, P., DArchivio, D., Lisanti, L., Di Luccio, A. & Perinetti, G.
(2002) Subpedicle acellular dermal matrix graft
and autogenous connective tissue graft in the
treatment of gingival recessions: a comparative 1year clinical study. Journal of Periodontology 73:
12991307.
Pini Prato, G.P., Baldi, C., Nieri, M., Franseschi, D.,
Cortellini, P., Clauser, C., Rotundo, R. & Muzzi,
L. (2005) Coronally advanced flap: the post-surgical position of the gingival margin is an important factor for achieving complete root coverage.
Journal of Periodontology 76: 713722.
Roccuzzo, M., Bunino, M., Needleman, I. & Sanz,
M. (2002) Periodontal plastic surgery for treatment of localized gingival recessions: a systematic review. Journal of Clinical Periodontology 29
(Suppl. 3): 178194; discussion 195176.

Shibli, J.A., davila, S. & Marcantonio, E. Jr (2004)

Connective tissue graft to correct peri-implant
soft tissue margin: a clinical report. Journal of
Prosthetic Dentistry 91: 119122.
da Silva, R.C., Joly, J.C., de Lima, A.F. & Tatakis,
D.N. (2004) Root coverage using the coronally
positioned flap with or without a subepithelial
connective tissue graft. Journal of Periodontology
75: 413419.
Small, P.N. & Tarnow, D.P. (2000) Gingival recession around implants: a 1-year longitudinal prospective study. International Journal of Oral and
Maxillofacial Implants 15: 527532.
Sorni-Broker, M., Penarrocha-Diago, M. & PenarrochaDiago, M. (2009) Factors that influence the position of the peri-implant soft tissues: a review.
Medicina Oral, Patologia Oral Y Cirugia Bucal
14: e475e479.
Zucchelli, G., Amore, C., Sforza, N.M., Montebugnoli, L. & De Sanctis, M. (2003) Bilaminar techniques for the treatment of recession-type
defects. A comparative clinical study. Journal of
Clinical Periodontology 30: 862870.
Zucchelli, G., Mele, M., Stefanini, M., Mazzotti,
C., Marzadori, M., Montebugnoli, L. & de Sanctis, M. (2010) Patient morbidity and root coverage
outcome after subepithelial connective tissue and
de-epithelialized grafts: a comparative randomized-controlled clinical trial. Journal of Clinical
Periodontology 37: 728738.

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