CLINICAL APPLICATION

Soft Tissues Remodeling Technique

as a Non-Invasive Alternative to
Second Implant Surgery
Xavier Vela, MD, DDS
Private Practice in Barcelona, Spain

Vctor Mndez, DDS

Private Practice in Barcelona and Madrid, Spain

Xavier Rodrguez, MD, PhD

Private Practice in Barcelona and Madrid, Spain

Maribel Segal, MD, DDS

Private Practice in Barcelona, Spain

Jaime A. Gil, MD, DDS, PhD

Chairman of Prosthodontic, University of The Basque Country,
Bilbao, Spain

Correspondance to: Dr Xavier Vela

Barcelona Osseointegration Research Group, Sant Mart 43-47, Sant Celoni 08470, Barcelona, Spain;
Tel: +34-938-675822; Fax: +34-938-674419; E-mail: headquarters@borgroup.net

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Abstract

area several times and always involves

It is currently accepted that success in

tissues. Careful surgical handling of the

implant-supported restorations is based

soft tissues when exposing the implants

not only on osseointegration, but also on

and placing the healing abutments (sec-

achieving the esthetic outcome of natu-

ond surgery) helps the clinician to obtain

ral teeth and healthy soft tissues. The so-

the best possible results, but even so

called pink esthetics has become the

there is a loss of volume of the tissues

main challenge in the implant-supported

as they become weaker and more rigid

rehabilitations in the anterior area. This is

after each procedure.

especially difficult in the cases with two

adjacent implants.

the surgical manipulation of peri-implant

The present study proposes a new

protocol that includes the connective

Two components affect the final peri-

tissue graft placement and the soft tis-

implant gingiva: a correct bone support,

sues remodeling technique, which is

and a sufficient quantity and quality of

based on the use of the ovoid pontics.

soft tissues. Several papers have em-

This technique may help to minimize the

phasized the need to regenerate and

logical scar reaction after the second

preserve the bone after extractions, or

surgery and to improve the final emer-

after the exposure of the implants to the

gence profile.

oral environment. The classical implantation protocol entails entering the working

(Eur J Esthet Dent 2012;7:xxxxxx)

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Introduction

obtain a predictable interimplant papilla

and avoid a traumatic second surgery.

It is currently accepted that success in

implant-supported restorations is based
not only on osseointegration, but also on
achieving the esthetic outcome of natural teeth and healthy soft tissues.

Gingival remodeling
To achieve a good prosthetic emer-

Over recent years, a large number of

gence profile, several of the surgical

papers have focused on the so-called

techniques that have been described

pink esthetic, and the majority of au-

can be used in the different stages of an

thors agree that it is difficult to ensure

implant treatment.811

that the gingiva around the implant-

Careful surgical handling of the soft

supported restorations has the same

tissues when exposing the implants and

thickness and height as is found around

placing the healing abutments (second

natural teeth. This is especially difficult

surgery), helps with obtaining the best

in the interimplant papilla, which is now

possible results.12 But even so, there is a

one of the greatest challenges in esthet-

loss of volume of the tissues as they be-

ic implant dentistry.1,2

come weaker and more rigid after each

Several papers have emphasized the

procedure.2

need to preserve the bone after extrac-

To prevent surgery causing side ef-

tions or to regenerate the lost bone be-

fects in the soft tissues, the present study

fore or during the implant-placement.

proposes a new protocol that includes

The bone not only fixes the implant but

the technique of soft tissue remodeling,

also plays an esthetic role, giving sup-

minimizing the logical scar reaction after

port to the soft

tissues.3

the second surgery and the loss of qual-

Nowadays the classical protocol proposed by

Branemark4

continues to be

useful and predictable. Three surgical

ity and quantity of the inter-implant soft

tissues. This new protocol involves two
steps:

steps compose this protocol: the extractions, the implant placement and some
months later, the second surgery, when
the implant becomes exposed to the
oral environment.

1st stage the connective tissue

graft placement
The function of the epithelium is to pro-

This second surgery usually means

tect the internal medium from the ex-

peri-implant bone resorption because of

ternal contaminated environment. The

the biologic width establishment5,6 and

connective tissue gives support, filling,

also a soft tissue scar reaction, which is

nutrition, and defense. To ensure these

especially important in a case with two

functions, the connective tissue is com-

adjacent implants, taking into considera-

posed of several collagen fibbers, posi-

tion the limitations to obtain an adequate

tioned in different directions.13

height of the interimplant

papilla.7

The first two functions are the ones that

The present study proposes the gin-

will help us most in improving our esthetic

gival remodeling technique as a way to

outcome, conditioning not only the gingi-

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VELA ET AL

val volume but also the response of this

tissue to prosthetic manipulations and
even preventing chromatic alterations.14
As it is possible to adapt and mold
this component to the shape of the temporary prostheses, the connective tissue will determine the so-called pink
esthetics of the implant supported re-

habilitations, which plays an important

role in the final prosthetic result. For this
reason, especially in the esthetic zone, it
is essential to achieve a good thickness
of moldable connective tissue.
Several techniques have been proposed to increase the connective tissue
thickness, depending on the protocol,
the placement of the graft when simultaneously seating the implants in the initial surgical stage; and more recently the

Fig 1 Adding compomers to the temporary toothsupported bridge. (a) First week (b) Second week
(c) Third week (d) Fourth week

type of incision, the location of the donor

site, the volume susceptible to earn.15-17
One of the most used procedures is

The present technique takes this con-

the subepithelial connective tissue graft

cept further, finishing when the ovate

technique, proposed by Langer and Ca-

pontic makes contact with the cover

lagna.15

The soft tissue graft is placed at

screw. Then, it can be replaced by a

a different surgical stage to the implant

healing abutment, thus avoiding a trau-

site, because in the esthetic zone it is

matic second surgery. This can be done

usual to augment the bone when plac-

using temporary prosthesis.24,25

ing the implants. This implies the use

of biomaterials and resorbable mem-

There are two possible options:

If it has been decided to use neigh-

branes, so reducing the vascularization

boring teeth as part of the restorative

of the recipient site and increasing the

treatment, then temporary tooth-sup-

risk of

necrosis.18

ported bridges will be used (Fig 1).

If neighboring teeth will not be in-

2nd stage: the modeling of the

augmented soft tissues through
the ovate pontics of the temporary prostheses

volved in the treatment, a removable

partial skeletal prosthesis is suggested (Fig 2), which will guarantee prosthetic stability. The prosthesis can
be the same as the one the patient

The use of ovate pontics has been wide-

has been wearing over the previous

ly described. Pressure is put on the soft

months since the exodontia, and

tissues to obtain the ideal emergence

will subsequently be used to help

profile.19-23

achieve an optimal esthetic result.

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Fig 2 (a) Adding compomers to the removable partial skeletal prostheses. (b) First week (c) Second
week (d) Third week (e) Fourth week

This type of partial prosthesis is less

achieving the ideal emergence profile

comfortable for the patient, but has

(Figs 3 to 5). The pressure on the soft

the advantage of easy access and

tissues must not be harmful, because

manipulation, and does not involve

the epithelium must preserve its integrity

aggression to neighboring teeth.

and the connective tissue has to recover

its normal vascularization after only a few

The pontic should be placed at a slight

minutes of ischemia. For this reason the

distance from the gingiva during the first

increased volume should not be greater

few weeks so it will not exert pressure on

than 11.5mm per week.

the grafts, which could compromise their

vascularization and cause necrosis.

The shape and volume of the ovate

pontics must be adapted to the needs of

The soft tissue remodeling starts one

the each particular case, and the weekly

month after the soft tissue graft place-

changes of the temporary prostheses

ment. Nonetheless, fluoroangiographic

have to be adapted to the evolution of

studies by Busschop et al show that

the soft tissues. This means that there

grafts are fully revascularized after 15

is not a pattern that marks the design

days; therefore, it could be possible to

of this technique. The surgical guide

start gingival remodeling even sooner.26

used for the correct positioning of the

The ovate pontics volume of the tem-

implants can help to guide the change

porary prostheses gradually increases

in the shape and volume of the ovate

week after week, adding an easy-to-

pontics in order to reach the implants.

handle light-cured biocompatible mate-

The objective of this technique is not

rial: compomers. The compomers have

only to achieve the ideal emergence pro-

shown their biocompatibility in class V

file but also to avoid a traumatic second

restorations, where the compomer is in

surgery. This means that the process

contact with the gingiva.

should be followed for four or five weeks

The changes of the shape and the en-

until the cover screws are exposed.

largement of the volume, lead the ovate

At the end of the process, only a thin

pontics to mold the gingival, gradually

epithelium layer is covering the cover

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i
Fig 3 Soft tissues remodeling technique. Clinical case with removable temporary prostheses. (a) Initial
situation (b) Stage 1. Immediate implant placement after extraction before hard and soft tissues grafts. (c)
Stage 2. Two months after implant placement, here starts the soft tissue remodeling technique. (d) One
week later (e) Two weeks later (f) Three weeks later. Notice the implant transparency in the occlusal view
(right). (g) Four weeks later: non-invasive second stage, impression copying test. (hi) One year after the
prosthetic placement and Rx.

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k
Fig 4 Soft tissues remodeling technique. Clinical case with removable temporary prostheses. (ab)
Initial situation (c) Stage 1 delayed implant placement and hard and soft tissue grafts. (d) Stage 2 six
months later. Here starts the soft tissue remodeling technique. (e) One week later (f) Two weeks later (g)
Three weeks later (hi) Four weeks later. Non-invasive second stage. (jk) One year after the prosthetic
placement.

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j
Fig 5 Soft tissues remodeling technique. (a) Clinical case with fixed temporary prostheses. (b) Stage
1 implant placement with hard and soft tissue grafts. (c) Fixed temporary prostheses. (d) Stage 2 six
months later. The soft tissue remodeling technique begins. (e) One week later (f) Two weeks later (g)
Three weeks later (h) Four weeks later the non-invasive second stage. (ij) Two years after the prosthetic
placement.

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screw. A screwdriver is usually enough

the implant abutments as a scar with

to pierce the epithelium, remove the

abundant collagen fibers and few cells.

cover screw and place the healing abut-

Berglundh et al33 observed that the vas-

ment or the impression coping.

cular supply in the free gingiva comes

This two-stages technique avoids the

mainly from the supraperiosteal vessels

second surgery, which would possibly

and the vessels of the periodontal liga-

damage the interimplant papilla, prob-

ment (Figs35).

ably the most sensitive area, and deter-

However the vascular system in the

mines the final outcome in a case with

peri-implant mucosa originates solely in

adjacent implants.

the large supraperiosteal blood vessel

outside the alveolar flange. This vessel
branches to form a plexus of capillaries

Discussion

and venules under the oral epithelium

According to literature, the most difficult

reported that there is no vascular plexus

area to obtain an adequate height of the

near the implant to compensate for the

papilla is the interimplant space. Some

lack of the periodontal ligament plexus.

and the junctional epithelium. The authors

papers agree that the average height of

Lindhe et al reported a diminished de-

the interimplant papilla, measured from

fensive capacity of the peri-implant gin-

the contact point to the interimplant

giva as compared to the periodontal gin-

bone peak, is 3.5mm compared to the

giva.34 This compromised situation was

6.5mm found between natural teeth.7

largely explained by the vascular deficit

Therefore, independently of bone lev-

in the supra-alveolar connective tissue.

el, the interimplant papilla always has

Thus, there is a considerable limitation

a lower height, and this conditions the

of the peri-implant soft tissues healing

esthetic outcome when comparing it to

in front of an aggression, eg, such as

the height of the soft tissues between

a surgical aggression. For this reason

natural teeth.7,27,28

it seems interesting to avoid a second

With this in mind, it seems of paramount importance to maintain the inter-

surgery, especially when there are two

adjacent implants in the esthetic zone.

implant bone peak, trying to minimize

The surgical treatment to expose the

the peri-implant bone resorption after

implants implies an open wound. The

expositing the implants to the oral envi-

second intention healing causes the

ronment. The new concept of platform

contraction of the tissues to reduce the

switching has led to a considerable re-

gap between the abutment and the mu-

duction in peri-implant bone loss with

cosa and the new epithelization guaran-

average bone loss values of 0.65mm

tees the closure of the exposed tissues.

on the vertical and horizontal axis.2932

These tissue reactions are particularly

The exposure of the implants to the

important when they affect the inter-

oral environment has been related to

implant tissues between two adjacent

peri-implant bone resorption and the

implants, causing an important loss of

soft tissues retraction. Some authors

quantity and quality of the inter-implant

have described the soft tissues around

papilla.

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The present technique described in

healing after removing the cover screw

this article is able to reduce the scar re-

and placing the healing abutments has

action of the peri-implant tissues. This

only to cover a minimum distance to en-

technique is based on the use of the

sure the biologic width establishment. A

ovate pontics. The ovate pontics modify

better vascularization of the peri-implant

the shape of the residual ridge by grad-

soft tissues and less scar reactions could

ual pressure over the gingival tissue,

be the consequence. Few changes oc-

improving esthetics and giving a natu-

cur after the exposure of the implants and

A gradual,

the gingival architecture remains similar.

controlled hyperpressure can transform

A minimum thickness of 3 to 5mm of

an unfavorable tissue configuration. This

soft tissue is required to improve the final

allowed a more natural, functional resto-

outcome.35 This measurement is record-

ration. There is also a possibility of clos-

ed from the gingival crest to the alveolar

ing undesirable black holes through pa-

ridge. Optimal results are realized when

pilla formation, by pressuring the tissue.

pressure is applied to thick tissues, al-

In the past, some believed that a pres-

though caution is needed regarding

sure over the residual ridge resulted in

its resilience.35 For this reason, soft tis-

an inflammatory process. Recently pub-

sue augmentation through subepithelial

lished data have shown that a well con-

connective tissue grafts is commonly

trolled hyperpressure, applied with a

required before starting the soft tissue

convex and highly polished pontic, asso-

remodeling technique.

ral look to our

restorations.35

ciated with rigid plaque control, resulted

in only a thinning of the epithelium with no
inflammation.35 Tripodakis and Constantinides36 showed that increased pres-

Conclusions

sure from smooth, polished, and glazed

The use of this technique can reduce the

convex pontics in patients with excellent

scar reaction of the soft tissues, which is

plaque control did not induce inflamma-

usually caused by the second surgery to

al37

expose the implants to the oral environ-

demonstrated that the mucosa under

ment. This effect is especially important

ovate pontics remained healthy, irrespec-

in the interimplant papilla of adjacent im-

tive of the pontic material used, when

plants in the anterior area.

tion in the adjacent tissues. Tolboe et

dental floss was used regularly. Zitzmann

The pressure of the ovate pontics

et al38 performed a histological evaluation

move the soft tissue, thus achieving an

of the alveolar ridge mucosa adjacent to

optimum emergence profile and main-

an ovate pontic after 1 year, showing that

tain the integrity of contact between the

these sites were not associated with overt

epithelial barrier and the cover screw,

clinical signs of inflammation.

so avoiding a traumatic second surgery.

The ovate pontics move the connective

This study concludes that the soft

tissue and the epithelium progressively

tissue remodeling technique based on

without damaging them. The pressure

the use of the ovate pontics can help to

does not break the epithelial barrier but

improve the esthetic outcome, and the

it moves it onto the cover screw. The final

predictability of these cases.

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