Dissertation

Soft Tissue Augmentation In Implant Dentistry

Abstract

This dissertation examines the soft tissue augmentation in implant dentistry. In ancient days there was no apt alternative to tooth loss. Replacement of lost tooth has been endeavour of the dental medicine for several decades. Placement of an implant at the site of lost tooth is one method of tooth restoration. Implant dentistry as the process is called has undergone numerous improvements over the years. This dissertation has reviewed the factors associated with tooth replacement, most important among which is the “soft tissue augmentation” around the site of lost tooth. Without adequate augmentation of the soft tissue, esthetics in the peri-implant site cannot be guaranteed. This dissertation explains about the normal esthetic consideration during an implant placement, maintaining the esthetic value after the treatment and preserving the esthetic outcome over a long period of time. It also explains the various surgical techniques performed for soft tissue integration.

Surgical techniques are implemented to improve the soft tissue defects present prior to the implant placement in order to establish a stable dentogingival unit and are also done after implant placement to improve the esthetics. The review of literature also included review of selected randomized control trials with the aim and objectives of examining the benefits and techniques of soft tissue augmentation and examining whether and when management and augmentation procedures are necessary in general and arriving at the most effective management and technique to augment soft tissues in particular. Review of randomized control trials shows that each case is unique and therefore there can be no single best method as “one size fits all” Rather treatment is based on the individual esthetics, soft tissue defect, underlying hard tissue defect, materials used and patient compliance.

Chapter 1: Introduction

Introduction: Esthetics in Implant dentistry

It has been seen that the evolution of dental implants over the years is of clinical importance. Predominantly the factors considered were only the hard tissue landmarks but today’s clinical expectation depends mainly also on the esthetic consideration from the clinical and patient’s perspectives. The need for soft tissue augmentation has been synonymous with implant placement in order to overcome several soft tissue defects or to establish a good peri-implant soft tissue environment. Several Esthetic and Anchorage considerations were established following numerous clinical studies and trials.

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This dissertation explains about the normal esthetic consideration during an implant placement, maintaining the esthetic value after the treatment and preserving the esthetic outcome over a long period of time. Also explains the various surgical techniques performed for soft tissue integration. Surgical techniques were implemented to improve the soft tissue defects present prior to the implant placement in order to establish a stable dentogingival unit and are also done after implant placement to improve the esthetics.
1.1 Aim and Objectives
Aim of this study therefore is to examine the benefits and techniques soft tissue augmentation in implant dentistry with the objectives of examining whether and when management and augmentation procedures are necessary in general and arriving at the most effective management and technique to augment soft tissues in particular.
1.2 Research Methodology
1.2.1 Type of study:
Randomized control trials done in patients with no significant baseline criteria. The studies taken into final consideration were studies conducted in the time period 2010-2012. However a study in 2002 was included to determine the good esthetic outcome. The evaluation was based on the final effective outcome which was determined on the mean increase in keratinized mucosa and esthetic scores. All the patients included in the study were followed for a minimum duration of 6months.
1.2.2 Research Methodology (Database researched)

The following journal databases were researched for the study:

Cochrane Database Systemic Review
Clinical Oral Implants Research
International journal of periodontics and restorative dentistry
European journal of oral Implantology
1.3 Dissertation Structure.
Apart from the above introductory chapter, there will be chapters on literature review and discussion and conclusion within the context of the aims and objectives stated above.

Chapter 2: Literature Review

2.1Anchorage and Esthetics for Implant Placement

Anchorage and esthetics are the two important factors for planning and treatment involving implants for replacement of missing teeth. Several anatomical factors including hard tissue and soft tissues play a role. During the treatment planning it is made sure that these factors are taken into consideration. While hard tissue factors usually play important role in the anchorage/support of implants and soft tissues play a role in the esthetics. In cases where there is deficient bone height, ridge augmentation procedures are done to provide good osseous support. Two stage surgical procedure is done when hard tissue augmentation is performed which allows healing period of 3-6months for the osseous integration to take place.

There is excessive bone resorption immediately following an extracted tooth and this remains as a problem making the bone height insufficient for implant anchorage. In the anterior region it becomes an esthetic problem when the ridge is narrow and pointed. Hence several methods were followed to improve this function and esthetic demand through surgical procedures . Several surgical techniques were employed to treat the horizontal and vertical alveolar defects.
Causes like trauma, extraction or periodontal diseases that cause alveolar defects require surgeries before the prosthetic replacement. Such alveolar defects need to be classified properly before being treated.

Classifications for Alveolar Defects

Qualitative Classification
Siebert Nomenclature 1983
Allen et al 1985
Wang & Al-shamari 2002
Qualitative Classification:
Horizontal: Labio-lingual defect with normal height of the ridge.
Vertical: corono-apical defect with normal width of the ridge.
Combination: Presence of both horizontal and vertical defect.
Siebert Nomenclature 1983
This presents with the same type of defects as presented in the qualitative classification.
Allen Nomenclature 1985
Type A
Type B
Type C

In 1996 Studer gave a semi-quantitative classification of the alveolar defects based on the severity of loss to their relationship with the dental arch and the adjacent papilla tip. This classification helped in determining the volume of the defect and the necessary treatment planning for the ridge augmentation.
Horizontal degree of severity was noted with the relationship of the arch curvature. Defect less than 3mm was said to be mild, 3-6mm as moderate and more than 6mm as severe. Similarly the vertical defect was classified based the relationship to the adjacent dental papilla. The measurements for the vertical severity were same as for the horizontal severity.

Prognosis of the treatment was classified based on the severity of the defects. A class I and mild horizontal loss showed very good prognosis whereas Class II and moderate horizontal loss showed good prognosis. Moderate prognosis was seen in class III and severe horizontal loss. A single tooth defect showed very good prognosis and two tooth defect showed good prognosis but three tooth defect showed moderate prognosis.

A number of surgical procedures are followed to improve and restore the deep alveolar ridge defects. According to Glossary of Prosthodontic terms, Ridge augmentation is defined as any procedure designed to enlarge or increase the size, extent, or quality of deformed residual ridge. There are two different types of treatment available to treat such alveolar defects:

2.1.1 Relative Ridge Augmentation and Absolute Ridge Augmentation.

Relative Ridge Augmentation is usually the deepening of the vestibule and floor of the mouth to improve the soft tissue relationship. Absolute Ridge Augmentation is done to treat the hard tissue alveolar defects which are usually done with bone grafts and allosplastic hydroxyapatite. Other techniques to restore deep alveolar ridge defects are the use of removable appliances in which acrylic serves to fill the defective ridge, cast framework partial denture or relatively inexpensive bridge construction can also be used .

The choice of treatment method depends on the extent of the alveolar defect that can be earlier identified by quantitative and qualitative assessment of the defect. Other factors that determine the treatment method and the outcome are treatment planning, esthetic points, prosthetic replacement to be used, patient’s compliance and financial possibilities.

2.2. Soft Tissue Augmentation in Implant Dentistry:

2.2.1 Soft Tissue Integration

Soft tissue integration and esthetic concerns play an important role in implant dentistry. An esthetic implant restoration requires in establishing a healthy relationship between the soft tissue, hard tissue and implant. The nature of the soft tissue is well studied and assessed after the loss of the tooth. It is highly essential to maintain the surrounding tissues immediately after the loss of tooth . The soft tissue integration helps to maintain the healthy biologic maturation between the soft tissues and the transmucosal part of the implant. Several clinical studies have suggested that maintenance of a health soft tissue barrier helps in improved Osseointegration and serves in long term life span of the implants. Maintenance of the peri-implant tissue plays an important role in the esthetic management of tooth replacement especially in the anterior region.
Such good care of the soft tissues helps in determining the outcome of the treatment. When there is inadequate soft tissue near the implant site, proper treatment planning and guidelines are to be followed to restore the soft tissue around the implant to provide a stable soft tissue environment.

2.3 Flap Management Considerations:

It is very important that the soft tissue and hard tissue in relation to the implant site to be in good periodontal health. In conditions were there is unstable soft tissue, the primary aim is to establish a stable periodontal environment. The replacement of teeth is always based that it should achieve both functional and esthetic demands. The peri implant site includes the periodontal unit that needs to be in harmony with the implant surfaces. The maintenance of this goal is established only after a proper integration of the connective tissue and the epithelium of the transmucosal site to the implant, this helps in producing a soft tissue seal .

It is ideal to establish the esthetic need by recreating the defective soft tissues site with ideal architecture and topography. Soft tissue augmentation is considered after a proper planning of treatment by evaluating the soft and hard tissue conditions in the implant site. Surgical guidelines should be followed to establish the quality, quantity and landmark of the normal adjacent soft tissues. When flap displacement is considered to improve the peri-implant site, it is necessary to assess the quality of the flap that is used for the treatment. It is made sure that the flap design has sufficient amount of bone available palatally or bucccally for the management of the site. Once a proper assessment is done and the flap design is according to the defect, the chances of any displacement or disharmony of the managed soft tissue is very less. Implant replacement usually involves the use of surgical template to perfect the placement of implant. Similarly surgical templates can be used to assess the treatment site for its quality during and before the treatment. Evaluating the normal anatomy of the dentogingival or the periodontal unit and the amount of soft tissue defect plays a major role in the treatment outcome.

2.4 Esthetic Considerations:

The evaluation of the esthetics zone is necessary during the treatment planning as it plays a major role in the treatment outcome. The concern for appearance is of wider importance as it improves the quality of the patient’s life. The following are taken into consideration during an esthetic replacement of missing teeth – Face, lips and the dento gingival unit. Maintenance of the facial symmetry while replacing an anterior edentulous site is of high value. The arch symmetry is also taken into consider during the management. The smile zone involves the healthy care of the fully designed lips, aligned dentition and a perfect gingival contour.

2.4.1 The Lips

Lips and the lip smile line as part of the esthetic zone is noted as an important factor. The smile line and lip profile is unique for all individual. The area comprising the parameter of the lips forms the anterior esthetic zone . The anterior gingival margin usually follows the architecture of the upper smile lip line. The smile line is defined as the position of the upper lip in relation to the maxillary teeth. It is also called as the upper lip line. The lower lip line is the relation of the lower lip to the maxillary teeth. The smile line is essential in establishing a good anterior esthetic zone .

Patient’s expectation is always minimally invasive and a fixed type of prosthesis which would serve efficiently for a long term. When it comes to the anterior region they also look for long lasting esthetic value and expect a replacement as similar to their natural dentition. These expectations are somehow met after establishing the soft tissue harmony and relationship with the hard tissue structures . The smile line is classified as high, medium or low lip line based on the relationship with the lips, teeth and the gingiva .

The different types of smiles are natural smile (patient’s normal smile), spontaneous smile and the exaggerated (forced) smile . The amount of exposure of the smile depends on the age, gingival margin, gender etc. The amount of tooth exposure in the anterior region is determined by this smile line. The position of the smile line varies based on several factors like function (rest, speech and smile), support, shape of the lip and level of the lip (high, medium and low).

The normal topography of the upper and the lower lip is always taken into account to provide a good esthetic result. The upper lip measurement is normally measured between the nasal point and the lower edge of lip. The average measurement of the upper lip ranges from 20-25 mm. Women have a shorter upper lip compared to men . A shortened upper lip shows a gummy smile which denotes a value usually below 20mm . The position of the lower lip also comes into account while establishing a good anterior esthetic zone. The margins of the lower lip usually should follow the margins of the maxillary teeth incisal edges and the level of the lower incisor incisal edge should be at the margin of the lower lip.

2.4.2 Gingival Esthetic Consideration

It is necessary that any treatment procedure in the maxillary anterior teeth requires the soft tissue around the teeth to be in harmonious with the structures. The gingiva is the most important aspect and it is essential to establish a good scalloped gingival contour in the maxillary region. The contour of the gingiva to be scalloped was established by Prichard in 1961. The amount of exposure of the gingiva depends on the patient’s smile. As seen earlier, the relationship and the contour of lips to the gingiva are essential as it determines the amount of gingival exposure.

The gingival margin is expected to be in the correct level to establish a harmonious relationship.

Symmetrical gingival tissue is to be maintained to appreciate the relationship between the natural and prosthetic dentition. The proper placement of Zenith is important and is usually at the peak of the curvature of the gingival margin. It is defined as the peak of the gingival marginal scallop. This zenith is located distal to the middle of the long axis of the teeth in case of central incisors, canines and premolars. For a lateral incisor, the zenith is along the midline of the long axis of the teeth. The extent of the gingival margin can range from 0.5 to 2.0mm coronal to zeniths of the central incisors and canine . In 2008, Kurtzman and Silverstein said that the gingival margin of the lateral incisor should be 1mm shorter than the adjacent teeth.

The zenith of the canine is usually slightly apical to the line of central incisors or the same level. Charreul and his co-workers in 2008 described that the gingival zenith is located along the distolabial line angles but after several studies by Mattos and Santana it was described that the distal placement of the zenith is not seen universally and it depends on the crown-root orientation. The gingival margins and the relating zenith line for all the anterior teeth are important for a sound clinical management of the dento-gingival complex.

2.4.3 Gingival Morphology

The gingival morphotype influences the crestal surface around the implant. A post-operative radiographic evaluation following Osseointegration shows a significant amount crestal bone loss which is usually around 1-2.0mm. The soft tissue thickness determines the amount of the crestal bone loss. Even when the implant is placed in a supra crestal position there can be bone loss of about 1.45 mm when the gingival thickness is 2.0mm. When the tissue thickness is more than 2.5mm, the amount of bone loss is around 0.25mm. The amount of bones loss also depends on the implant-abutment junction, only a significant bone loss of about 0.2 mm can be seen if this position is 2mm above the bone level. When there is a thin gingival biotype, the placement of implant in the bone level is avoided. This situation can be avoided by converting it to a thick biotype by augmentation methods. Few studies by Linkevcius in 2009 determined that the bone loss around the implant surface to be inversely proportional to the peri-implant tissue thickness.

A thick peri-implant mucosa showed more than 3.1mm loss and thin peri-implant mucosa showed less than 2mm bone loss. Hence it is necessary to determine the gingival biotype during the treatment planning prior to implant placement as it plays an important role in the influence of the amount of bone less. However it is difficult to establish the morphotype accurately as the morphology is unique for individuals. Gingival recession and discoloration is of less risk when the gingival biotype is less. The risk of recession is higher with a thin gingival biotype but the quality of the tissue around the around the implant doesn’t influence the implant survival. However, the quality of the tissue around helps in a stable peri-implant surface.

2.4.4 Gingival Recession:

It is one of the important aspects of anterior esthetics as it is the most common complication following a single tooth implant replacement in the anterior zone . It is said that it is easy to preserve the soft tissue and hard tissue in case of immediate replacement as there is less amount of tissue defects. However, accurate treatment planning and surgical skills are required to establish a good gingival contour following an immediate replacement. The gingiva heals sooner following the implant placement. The amount recession here depends on the thickness of the gingival tissue as discussed earlier.

2.4.5 Relative Tooth Position:

The existing tooth represented the gingival architecture of the remaining teeth and hence the tooth has to be evaluated in three dimensions. The cervical portion of the teeth may be more apical, coronal or at a level perfect to the free gingival margin . There can be upto1mm of apical migration of the facial free gingival margin in the implant site. This measure of the position of the free gingival margin is measure in the apico-coronal plane or the vertical place. In such cases when there is an assured gingival migration to take place after wound healing, it is essential to have a healthy gingival tissue surrounding. The facio-lingual plane determines the position of the tooth either facially or lingually. When the tooth is position is placed relatively more facially then the amount of buccal cortical bone will be less and the covering soft tissue thickness also varies. This relative position of the tooth determines the amount of bone present for the implant placement. Finally the third dimension for measuring is the mesio-distal orientation of the tooth .

The concerns while measuring the mesio-distal orientation is the amount of space available in the proximal surface and the quantity of the interdental papilla. Increased interdental papilla volume denotes that the amount of bone thickness will be more which signifies that the bone resorption with implant placement will be minimal and affects the soft tissue contour in a less significant way. In an anterior teeth replacement, the inclination of the tooth also means that the contact point of the tooth is more incisally and the volume of the interdental papilla will be more and hence the soft tissue migration and bone resorption will be of less importance. The mesial inclination of tooth is usually an advantage in such cases. Similarly when diastema is present, the volume of interdental papilla and underlying crestalbone will be of sufficient quantity and hence after wound healing it achieves a good soft tissue contour .

2.4.6 Interproximal Dental Relation

Tarnow et al in 1992 suggested few notes based on the height of the papilla, apical contact point and the interproximal bone level. Increase of distance of each by 1mm is inversely proportional to the level of papillary regeneration.

2.4.7 Interproximal Implant Relation:

Esposito et al , Saadounet al , Tarnow et al suggested that the management of the interdental papilla depends on the relationship with the adjacent tooth, implant-tooth relation, implant-implant relation, pontic relationship to the adjacent tooth. Several such factors add to the esthetic concerns during the implant placement. Certain criteria were established with these factors. They included both horizontal and vertical dimensions relating to the implant placement.
2.4.7.1 Horizontal Criteria:
Distance between the implant and adjacent teeth: 1.5–2.0 mm
Distance between the implant and central incisors: 2.0-2.5mm

Distance between two adjacent implants: 3–4 mm

Distance between two maxillary central incisor implants: 4.0–4.5 mm.
2.4.7.2 Vertical Criteria:

Bone crest-tooth contact point restoration: 5 mm

Bone crest/tooth–implant contact point restoration: 4.5–5.0 mm
B one crest/implant–implant contact point restoration: 2.3–3.4 mm
Bone crest/implant–pontic contact point restoration: 5.5–6.0 mm
Bone crest/tooth–pontic contact point restoration: 6.0–6.5 mm
Bone crest/pontic–pontic contact point restoration: 6.0–6.5 mm
These guidelines were established to restore the health, function and the esthetics of the peri-implant site which includes the gingival tissue, gingival margin and the interproximal papilla. The most important factor determining the crestal bone loss after implant placement depends on the volume of the interdental papilla. A thick papilla shows very minimal bone loss and less soft tissue apical migration.

A summary of the esthetic considerations are shown below:

Lip line: Position of the smile line – High/Medium/Low
Gingival Biotype: Thick or Thin – Location of the Zenith line
Interocclusal relationship
Relationship between adjacent tooth, implant.
Soft tissue quality and quantity – Type of smile, Gingival Thickness, asymmetry, recession.
Hard tissue consideration- Horizontal and vertical evaluation for assessing the need of soft/hard tissue augmentation.
Radiographic Evaluation- Bone height, position and inclination of the tooth/roots.
2.5 Biologic Space
The placement of the implant involves the surrounding dentogingival unit and hence it influences the biologic space. The placement of an implant restoration at the free gingival margin alters the biologic space. The chances of the affecting the biologic space is more when there is less 2mm of gingiva between the restoration margin and the alveolar bone. This defective management may lead to periodontal inflammation and infection. Hence the above mentioned criteria are very important during the treatment planning of a single or a multiple tooth implant. Hence certain scores for assessing the soft and hard tissue have been established to improve the treatment planning.
2.6Esthetic Scores:

Pink/White Esthetic Scores: PES or WES

Certain parameters contribute to the evaluation of the PWES scores which include the gingival tissue, adjacent teeth and the implant restoration. A scoring system had been established to assess the osseous and the gingival state prior to the treatment during the planning.
2.6.1 Pink Esthetic Score:

Pink Esthetic score represents the gingival contour:

Gingival Contour Rate
Mesial papilla 0–2
Distal papilla 0–2
Level facial mucosa 0–2
Curvature facial mucosa 0–1
Root convexity 0–1
Soft tissue colour 0–1
Soft tissue texture 0–1
Score (10 being the best) 0–10
2.6.2 White Esthetic Score

White Esthetic Score represents the final tooth restoration:

Final Tooth Restoration criteria Rate
Tooth form 0–2
Tooth outline and volume 0–2
Color (hue and value) 0–2
Restoration surface texture 0–2
Translucency and characterization 0–2
Score (10 being the best) 0–10
2.6.3 Papilla Fill Index:
Papilla Index score – PIS was established in 1997 by Jemt based on the loss of interdental papilla. This was measured with five grades from 0 to 4. This index provided an idea regarding the measure of interdental papilla in the mesial and distal aspect with relation to the dental implant and the adjacent teeth .

Scores:

2.6.4 Implant Crown Esthetic Index
Implant Crown Esthetic index measured 9 variables based on the esthetics of implant supported single prosthesis and the adjacent soft tissues. This index with 9 variables were divided into three parts with four them with a five point rating scale, remaining five items with a three point rating scale .
2.7 Rationale for Soft Tissue Augmentation:
The need for soft tissue augmentation around the placed dental implant is determined with relation to the surrounding soft tissue of the dental implant. This is an outcome from a clinical aspect rather than a method opted from a number of studies. Several changes to the soft tissue occur following an extraction, tooth preparation, implant placement, impression procedure and during prosthesis placement. The soft tissue quality needs to be maintained in harmony in order to provide a good esthetic result and implant life span with fewer complications. Inflammatory changes of the peri implant mucosa and underlying structures depends on the alteration of the tissues during the treatment process as seen earlier. Several factors contribute to the gingival biotype and its disintegration. Such factors are age, general health, host resistance, periodontal unit, oral hygiene status, surgical technique, margins of the restoration, restorative materials used, placement of the implant, depth of implant placement, bony architecture, surface features of the implant, quality and quantity of the surrounding soft tissue in the apico-coronal dimension. Clinically it is essential to assess the above mentioned factors to maintain good peri-implant biology to have a successful treatment outcome .
2.8 Clinical Guidelines for Soft Tissue Augmentation
Soft tissue augmentation is considered mainly when the apico-coronal dimension of the attached soft tissue to the buccal flap is less than 3mm. The quality of the tissue, thickness of tissue, periodontal status, type of implant restoration planned is considered during the guidelines for augmentation. In case of less than 3mm of attached tissue, an epithelialized palatal mucosal graft is indicated prior implant placement in the esthetic zone. Supepithelial connective tissue grafts can be used in cases of minimal soft tissue defects along with the placement of submerged or non-submerged implants. Vascularised interpositional periosteal connective tissue flap is done in case of large soft tissue ridge defects.
2.9 Principles for Oral Soft Tissue Grafting

High Vascularization

Immobilization of the Graft Tissue
Establish Haemostasis
Size and Thickness- Graft and Donor area
2.9 .1 High Vascularization:
The recipient site must be of high vascularisation as the free grafts survive by plasmatic diffusion initially and then get blood supply permanently from capillaries and arterioles in the graft region. When the graft area is avascular it is possible that there is denuding of soft tissue on the implant surface or apical migration of the graft resulting in gingival recession which is unacceptable in the esthetic zone.
2.9.2 Immobilization of the Graft Tissue:
The most important thing next to any healing process next to vascularisation is rigid immobilization of the graft tissue. The soft tissue graft needs to be properly adapted to the recipient area. The nourishment of the graft via vascularity is dependent on the mobilization of the graft during the initial healing period. Reduced nourishment due to mobilization of the flap can result in the shrinkage of the grafted tissue and results in augmentation failure.
2.9.3 Establish Haemostasis:
The key for the success of soft tissue grafting is achieving adequate haemostasis. Active and profuse bleeding interferes with the integration of the graft and the recipient area. The haemorrhage interferes with the fibrin network that helps in the soft tissue attachment and which serves as network for nourishment. Proper preparation of the recipient site helps in the intimate adaptation of the soft tissue graft to the recipient site. The most suitable site for oral soft tissue grafts is usually the periosteum as it fulfils the above requirements.
2.9.4 Size and Thickness:
Any grafting procedure requires the donor tissue to provide good vascular circulation, adequate area for immobilisation and proper size/thickness. The graft must be thick so that it is possible to attain the needed augmentation of the soft tissue once the healing process is successful. The graft needs to provide sufficient coverage for the tooth and the abutment during the healing period to prevent necrosis of tissue. A graft of thickness more than 1.25mm is indicated to avoid necrosis.
Adequate evaluation of the donor and the recipient area is necessary by following the above principle to avoid complications like less volume of soft tissue, graft disintegration, necrosis, breakdown of wound and peri-implant infection etc. Hence it is clinically essential to follow the principles during the soft tissue augmentation.
2.10. Surgical Techniques for Peri-Implant Soft Tissue Management

Resective Contouring

Papilla regeneration
Lateral Flap advancement
Flap management considerations have already been discussed to provide an optimal soft tissue environment. For an edentulous mandible, the design includes a midline vertical incision and distal releasing incisions that is made behind the area where implant placement is indicated or planned. A peri-crestal incision is made for a submerged placement. Incision for edentulous maxilla is a para-midline vertical releasing incision and vertical incision placed beyond the area of implant placement similar to the edentulous mandible. Similarly flap design for edentulous mandible is margined by pericrestal and curvilinear bevelled vertical releasing incisions. Guidelines presented for soft tissue grafting is followed to establish the essential soft tissue peri-implant environment.
2.10.1 Resective Contouring:
This surgical method is adopted only when the attached soft tissue remaining on the buccal flap that is used for abutment connection or in a non-submerged implant placement is between 5-6mm. A fine scalpel blade used for gingivectomy is made on the buccal flap corresponding to the shape of the implant placed around its neck. Similarly contouring is done for the adjacent implants placed. This resective contouring done facilitates the circumferential integration and adaptation of the soft tissues of the peri-implant environment.
2.10.2Papilla Regeneration:
This method is preferred when the interdental papilla volume is less. It is indicated when the apico-coronal dimension of soft tissue on the buccal flap is between 4-5mm. This surgical technique was widely advocated by Palacci and colleagues .
2.10.3 Lateral Advancement Flap technique
This is indicated when the apico-coronal dimension on the buccal flap used for implant placement is between 3-4mm.This method is done in completely edentulous or posteriorly partially edentulous patients. Lateral Flap advancement technique involves the flap design to extend beyond the site of the implant placement to include the soft tissues of the adjacent edentulous region. During the healing period, the flap advances around the implants and necessary soft tissue augmentation is achieved.
2.11 Other Surgical Techniques and Clinical Cases
2.11.1 Epithelialized Palatal Graft Technique for Dental Implants
Epithelial Palatal Graft placement technique is indicated and successful in treatment of mucogingival defect . This technique is used for the increasing the dimension around the implant and the natural dentition. This is also essential in procedures for coverage of denuded root or abutment surface. The graft is usually a split-thickness graft which is more than 1.25 mm or a full thickness graft that is harvested from the palate.
This general surgical technique which uses the palatal graft tissue for gingival grafting is the most effective grafting technique for natural dentition and implants . When the grafting is done after the final abutment placement, the horizontal incision is placed from the interdental papilla to a necessary height and then followed by gingival grafting that is necessary for coverage. If the grafting is done after the second stage of surgery or in a submerged implant, mucoginigval junction is the site for horizontal incision and reposition of the gingival tissue is done. A split thickness graft on the buccal part of the alveolar ridge serves as a site for rigid immobilization of the donor graft; this procedure helps in the adaptation of the soft tissue around the implant. This type of grafting is advocated in severely atrophied mandible whose bone height is less than 10mm or attached soft tissue less than 3mm.
2.11.2 Subepithelial Connective Tissue Grafting:
This technique indicated only when the vestibular depth is good and the thickness of the gingiva is adequate to lift a split thickness flap. This technique also involves the use of palatal autograft from the donor site which is placed beneath the spilt thickness pedicle flap. This technique was first advocated in 1985 by Langer B and Langer L . Similar techniques were suggested earlier by Pervez Fernandez and Raetzke .
This type of augmentation technique usually is beneficial and the graft tissue usually enjoys a dual vascularisation from the split thick pedicle flap and the underlying periosteum. This rich nourishment enhances the primary closure and wound healing very effective . The abundant blood supply in the recipient site makes the subepithelial connective tissue graft procedure less technique sensitive, easy to perform and results in a good outcome. This can be done during the site maintenance prior to implant placement or for correction of soft tissue defects along with the submerged implant placement. Large volume defects are corrected by a series of sub-epithelial connective tissue connective grafts.

Surgical Technique:

Two variations are presented during a sub-epithelial connective tissue graft placement – Single incision and Dual incision technique. In a single incision technique, only a single incision parallel to the gingival margin is made to access the donor site for preparation and harvesting of the graft. Grafts of variable size and thickness can be obtained. Since it is only a spilt thickness flap and that no epithelium is removed, the connective tissue graft is allowed to heal by primary healing. The use of stents or any haemostatic substance post-operatively is not very necessary and the suturing is also minimal.

Step1: This involves the preparation of the recipient site by elevating a split thickness flap. First, a horizontal incision is made at least 2mm from the tip of the interdental papilla which is followed by two vertical incisions extending to the depth of the mucobuccal fold. The vertical incision has to be 1-2mm from the gingival margin of the adjoining teeth. The width of the flap mesio-distally should include at least half of the adjacent teeth without any soft tissue defect. The flap has to be large and with good width as it heals better with rich nourishment during the primary healing.

Step 2: This includes the obtaining of graft from the donor site which is usually the palate. Single or dual incision type of the incision may be used to take the flap. A curvilinear incision is made at least 2-3 mm away from the gingival margin in the premolar region. The depth of this full thickness graft should be at least 1mm. Spilt thickness graft is taken by using dual incision technique and full thickness graft in single incision technique. In a dual incision technique, the second incision is placed 2mm apical to the first incision and a scalpel is used to dissect the tissue by placing it parallel to the palatal surface. This creates a rectangular pouch of the donor tissue. The donor tissue is gently removed by using forceps and it is kept in sterile gauze moistened with normal saline before placing in the recipient site. Adequate thickness of the donor tissue prevents denuding or sloughing of the tissue after the placement. The donor tissue is then placed in the recipient site and haemostasis is obtained by placing good dressing which is sutured later. The graft is secured well in the recipient site and it adapted apically also to avoid blanching of the mucosa. Depending on the volume of the soft tissue defect, the flap may be sutured by placing it coronally. The graft is secured by placing interrupted sutures with the graft tissue and the interproximal tissues. Closed or open technique may be followed to correct the vertical soft tissue defects around the natural tooth and the implant restoration.

2.11.3 Vascularised Interpositional Periosteal Connective Tissue Flap

This method is followed when the large volume soft tissue defects are to be corrected in a single procedure. The volume of soft tissue augmentation produce in horizontal and vertical dimension by this technique is more than the volume produced in free gingival graft procedures. This technique due to high vascularity serves a very good proven technique to improve the soft tissue esthetics in the anterior zone with implant placement.

The recipient area involves the preparation of a spilt thickness flap followed by de-epithelisation of the col and papillary area. The buccal aspect of the implant site is also de-epithelialized before the implant placement. The donor site incision starts 2-3mm apical to the gingival margin of the cuspid and extends only within the premolar region. After the subepithelial horizontal dissection, a deeper vertical incision is placed and is advanced as apically as possible without damaging the neurovascular palatine structures. Adequate thickness of the palatal flap needs is indicated to avoid sloughing of tissues. A Buser’s elevator is then used to gently elevate the flap from the canine to the premolar region following the incision. A horizontal incision is made from the extent of the vertical incision from the premolar region extending till the canine region crossing the midline. Buser’s elevator is used to elevate the spilt thickness flap. This elevated flap is then rotated and placed over the spilt thickness recipient site. The recipient area is then sutured apically or laterally with the donor tissue placed. If a bone graft is used then the palatal graft is placed over the bone graft and sutured with absorbable sutures. Haemostasis is achieved by placing absorbable collage dressing.

2.11.4 Oral Soft Tissue Grafting With Acellular Dermal Matrix

Technique involved in acellular dermal matrix (alloderm) grafts is similar to the sub-epithelial and connective tissue grafts. This is a very good alternative for the above mentioned graft techniques as it reduces the surgery time, no involvement of any donor site, good vascularisation in the recipient area and improved patient comfort. Alloderm is an allograft skin that is freeze dried and processed to remove all immunogenic cellular components like epidermis, dermal cells, leaving only a regenerative collagen matrix. This acellular matrix is responded as a normal tissue by the host tissue, hence reducing the chance of any inflammatory or periodontal infection. Alloderm provides results as good as palatal tissue grafts ,, , .

This allograft is placed over soft tissue defect with the simultaneous placement of implant. It is necessary to identify the sides of the graft- basement membrane and the connective. The side which retains the red colouration on staining with the recipient’s blood is the connective tissue, while the basement membrane remains white. The connective tissue side is placed towards the tooth or the implant surface and then surface similar to other techniques. Secondary shrinkage of the graft and poor healing time are disadvantages of this technique. This technique yields very good peri-implant environment with good post-operative care.

Several other techniques like Guided Tissue Regeneration, Pouch and Tunnel Technique, Coronally Displaced Flap that are done for periodontal plastic surgeries to improve the esthetic outcome by reducing the amount of gingival recession or by covering the denuded surface can also be applied to improve the peri-implant site after the implant placement.

2.11.5 Allogenic grafts, Xenogenic grafts and Guided Tissue regeneration to improve the implant esthetics.

Xenografts are obtained from other organisms and placed in the recipient site. FDA- Food and Drud Administration issued the approval of use of Xenogenic Bioabsorbable collagen matrix (XBCM) in implant surgical sites . This Xenogenic graft material was intended to use in peri-implant and around the tooth to improve the soft tissue esthetics. Xenogenic bio absorbable collagen matrix is made of type I & type III collagen of pure porcine and it is sterilized by gamma radiation . This bilayered collagen matrix has outer smooth cell layer and inner thick roughened porous layer with a total thickness of 2.5mm. The inner smooth cell layer is primarily composed of the type I and III collagen fibres whose function is to enhance/promote the tissue adherence and wound healing. The inner thick porous layer is positioned on the host tissue and facilitates in blood supply and tissue growth. The flap elevated in the recipient area is similar to the technique used in free gingival graft procedures but the use of this XBCM grafts reduce the surgical time as no donor tissue is obtained from the patient. This less invasive procedure improves the patient compliance and is an opted technique in recent times .

Guided Tissue Regeneration:

Guided Tissue Regeneration (GTR) membrane is usually a barrier membrane which is non-absorbable or bio-absorbable in nature . The concept involvement in the placement of a GTR membrane over the root surface after flap elevation is that the site eliminated from local factors like plaque, micro-organisms that restricts the tissue re-growth. This enables in making the surface devoid of any undesirable entity and thereby allows healing, generate bone, enhance periodontal ligament fibres growth and cementum growth which thereby helps in root coverage and increase in clinical attachment. This facilitates in improving the soft tissue volume and quality around the teeth. The advantages involved are same as in xenogenic grafts but this method is technique sensitive .

Clinician skill with other factors like plaque, recession depth, flap thickness and root surface bio-modification play an important role in treatment outcome. Hence GTR membrane is widely indicated only in healthy individuals to yield to good treatment outcomes as they have good plaque level, mild-moderate recession (less or equal to 4mm) and flap thickness more than at least 1mm .

Biological agents in esthetics:

Apart from graft materials, natural growth factors or biological mediators can also be used to regulate/promote the wound healing and tissue proliferation which enhances the soft tissue environment. Biological agents used were Enamel matrix derivative (EMD), platelet derived growth factor (PDGF) and platelet rich plasma (PRP) . Emdogain is an acid extract of porcine amelogenin, porcine rich non-amelogenin, tuftlin, enamelin, ameloblastin, tuft protein, metalloproteases, serine proteases, transforming growth factor beta, propylene, glycol alginate and water ., Emdogain aids to promote epithelial, endothelial, gingival and the periodontal fibroblast attachment. EMD also stimulates the bone morphogenic proteins from macrophages leading to the production of cementum alike structures and also induces biomineralization. EMD is usually used along with root coverage procedures. Emdogain has also been used to effect the proliferation and the differentiation of osteoblast on the implant surface and thereby facilitation the bone modelling around the implant surface. The hard tissue morphology proportional relates to the above soft tissue volume and quality that aids in the peri-implant esthetics.
2.12 Clinical Case Studies:
Several soft tissue considerations were taken into note to plan a proper treatment procedure for improving the soft tissue condition of the peri-implant surface which helps to cope up the esthetic value. It was necessary to evaluate the best surgical technique that can be put into practise which will be surgically easy to perform to obtain excellent post-operative results.
As discussed earlier, a number of soft tissue considerations had to be keenly followed so as to bring in an effective treatment plan and outcome.
The need for soft tissue augmentation arises due to the soft tissue defects alone or with hard tissue defects as well. The periodontal unit or the peri-implant environment is considered before any surgical procedure for producing a good esthetic result. The thickness and the adequacy of attached gingiva is the key for soft tissue augmentation procedure.
2.12.1 Classification of Soft Tissue Defect and Flap Consideration

The thickness of the attached gingiva around the teeth is also used to determine the treatment plan .

Both these techniques help in improving the zone of keratinized tissue around the implant. Free gingival graft technique is an ideal technique performed to improve zone of keratinized tissue.
2.12.2 Clinical Cases

Study 1: Tissue Grafting vs Non Tissue Grafting to evaluate esthetic and peri-implant tissue environment.

Wiesner et al performed surgery comparing the soft tissue grafting in implant tissue against non-grafting technique in posterior mandible. A split thickness flap was elevated after placing crestal incision and one implant placement was done on either side of the mandible. Immediately after the implant placement, one site was augmented with a soft tissue sub-epithelial connective tissue graft taken from the donor site which is usually the palate. Flap was sutured with 6-0 absorbable sutures and ensured that it covers both buccal and the lingual side. During the healing period of 3months no temporary prosthesis were given and the surgical site showed good healing. The implants were exposed after the healing period and permanent crown was placed after 1 month followed by maintenance once in 3months.
This split mouth study was done in 10 patients with no significant baselines differences. This two stage implant techniques with soft tissue augmentation did not show any implant failure or post-operative complication. The site which was augmented showed very good Pink Esthetic Scores than non-augmented sites. This procedure showed a mean different of -2.87, 95% Controlled Interval -3.67 to -2.07. Out of the 10 patients, six patients preferred esthetically and the remaining four did not have any preference. The sites in which augmentation was done showed significant improvement in the peri-implant tissue on the buccal aspect with mean difference -1.35mm but there was no significant improvement in the peri-implant crestal bone level or thickness. Showed only a mean difference of 0.17mm

Study 2: Effective Technique to increase the zone of keratinized tissue.

Graft material was used to study and compare two techniques to improve the thickness of the keratinized mucosa in the peri-implant site. This was performed in 12 patients with less than 1mm of keratinized mucosa in the peri-implant environment. The graft material was either a Xenogeneic collagen matrix contains porcine or connective tissue autograft from the donor site (palate). The patients were not chosen based on any significant baseline differences. There was no implant failure reported after this procedure. Both techniques were able to achieve a good width of keratinized mucosa but no significant differences were seen with different graft material. The Xenogeneic graft material presented with a thickness of about 2.4 mm keratinized tissue whereas the autograft showed increase in 2.3mm of tissue. Post-operatively there was no significant difference in the gingival recession but both the techniques presented with the same amount (0.4 – 0.5mm) of gingival recession which resulted in the exposure of titanium abutments. Post-operative pain data and colour of the tissue to determine change in esthetic score were not documented properly .

Study 3: Connective Tissue Graft to improve implant esthetics – Study of 2 patients

Patient 1(9): A 50 year old male patient reported with a complaint of missing central incisor in the second quadrant and wanted a permanent replacement. Clinical evaluation showed no mobility of the dentition but was presented with mild generalized gingival recession. The treatment site also showed mild labial defect which had to be corrected before the treatment. Immediate loading implant protocol was the treatment of choice which begun with anti-biotic regimen pre-operatively for 3days (500mg amoxicillin for every 8hours) . This procedure used a modified roll flap technique in which the recipient site had two vertical incisions starting from the crest of the ridge labially to the palate with split thickness connective palatal tissue dissection. The implant was placed immediately to maintain the contour of the connective tissue in the peri-implant site. The extended connective tissue was then rolled and sutured. Post operatively anti-biotic regimen was followed for 4days. Healing abutment was placed during the surgery . After a healing period of about 6weeks, a permanent metal-ceramic restoration was given after removing the previously removable prosthesis placed during the healing period . .
Patient 2: A 46 year old patient presented with esthetic complains in relation to the placed implants and in natural dentition. Clinical examination showed uneven gingival contours and two implants placed in the maxillary right central incisor and lateral incisor; well Osseo integrated implants were seen on radiographic examination. Two grafting procedures were suggested in this treatment planning .
Antibiotic regimen as suggested in the previous case was followed pre-operatively and post-operatively. The first incision, horizontal supra-periosteal incision was placed below the mucogingival junction and the attached mucosa was coronally by dissection from the periosteum. The coronal position of the flap is placed to the level of the determined esthetic gingival contour. A sub-epithelial connective tissue graft was placed under the flap and sutures were placed in the inter-implant site. To improve the contour of the recipient site, free gingival onlay graft was taken from the palate and was placed in the recession site to maintain the soft tissue contour. The reason for two grafts is that the coronal positioning of the flap helped in improving the gingival margin and the second sub-epithelial graft was placed to stabilize the contour of the inter-implant site. Rolled out technique is done to stabilize the contour of the inter-implant papilla.
The maintenance of the normal gingival tissue volume, contour and the architecture of the peri-implant site involves several augmentation procedures which is decided based on the zone of the keratinised tissue, mucogingival junction, tissue type of implant, time of placement etc. In some cases, the placement of onlay gingival graft helps in maintaining the over contour of the peri-implant site. This soft tissue grafting helps in treating minor tissue defects and provide good esthetic outcome . .

Study 4: Xenogenic Collagen matrix for soft tissue augmentation around dental implants.

Lorenzo et al studied the efficiency of the usage of collagen matrix in the peri-implant site by conducting a randomized control trial. The studied aimed at evaluating the efficacy of the xenogenic graft material to augment keratinized mucosa around the dental implant. The study was conducted in 24patients with at least 1mm of keratinized mucosa. The use of xenogenic collagen matrix was compared with the use of connective tissue graft. The patients were evaluated for a time period of 6months in total. The patients who received xenogenic collagen matrix showed an average thickness of 2.80mm of keratinized mucosa and the patients who received connective tissue graft showed 2.75mm thickness. The mean difference in the thickness of the tissue formed was less significant. However, patients who received xenogenic collagen matrix showed better healing rate, less surgical time, good patient compliance and less pain medications. The outcome with the collagen matrix material was not very significant with the result produced in the other group treated with connective tissue graft. This study helped in proving the effectiveness and the predictable positive outcome of xenogenic collagen matrix material used .

Study 5: Resorbable Collagen matrix for soft tissue augmentation

The use of xenogenic resorbable collagen matrix to yield good outcome in the anterior esthetic zone has been questionable. This material aimed at improving the soft tissue quality in the peri-implant region. The 6 patients included in the study had be previously undergone bone regeneration procedure and this study aimed at determining the use of collagen matrix grafting procedures in increasing the soft tissue volume in the anterior maxillary site. The collagen matrix was infused with recombinant human platelet-derived growth factor BB (rhPDGF-BB) in the two stage implant surgery. The final outcome in the increase of soft tissue thickness was measured apically, centrally and occlusally for each surgical site. The average gain in the soft tissue thickness in the study were 0.87 ± 2.13 mm(apical), 2.14 ± 3.27 mm(central), and 0.35 ± 3.20 mm(occlusal). Simon et al in this study proved that good significant outcome in the soft tissue quality can be achieved with xenogenic collagen matrix grafting procedures .

Study 6: Connective tissue graft in the anterior maxillary region

A 40 year old patient reported with the complaint of discoloured front teeth. Clinical examination revealed discoloured, migrated and mobile left upper central incisor with a thin gingival biotype. Immediate implant with soft tissue augmentation was considered as the treatment plan. Initially, left maxillary central incisor was extracted under LA and followed by the elevation of flap in relation to the same site with two unilateral vertical incisions preserving the interdental papilla. Implant was placed in this site and a connective tissue graft was placed in the region of the elevated flap. Horizontal apical sutures were placed were followed by interrupted suture to secure the graft in the coronal position. Post-operative evaluation of the surgical site showed a good improvement in the soft tissue prototype .

Chapter 3: Data Findings, Discussion and Conclusion:

A number of soft tissue and hard tissue defects seen in the peri-implant site has to be determined and corrected properly. Several esthetic considerations include the gingival contour, volume, morphology and the architecture in the peri-implant site. These considerations also are related to the underlying bony defects too; hence the bony defects are also to be corrected prior to the soft tissue augmentation. Techniques like free gingival connective graft, sub-epithelial connective tissue grafts, Xenogeneic grafts were placed to stabilize the soft tissue contour. Based on the 6 randomized control studies which were done in 55patients in total, a final data on the improved soft tissue volume were tabulated. The significant difference in the post-operative soft tissue was recorded in the peri implant region to identify the best method.
Based on the articles from the online databases, a total of 6 randomised control trials with 55 patients were initially taken into the study. However the data for two studies were not available to be taken into data summary. Finally the data for 53 patients were taken into consideration to determine the effectiveness of the treatment used. The study design used was either a split mouth study or a parallel group study and the minimum follow up duration was 6months. The treatment procedure mainly included the use of autograft or xenogenic graft materials. Both showed a very good improvement in the amount of keratinised mucosa around the implants. The final conclusion is predominantly based on 4 clinical trials on 53patients which were summarised according to the gain in the increase of keratinized mucosa and esthetic outcome in the peri-implant site. The follow up duration in all the studies was a minimum of 6 months.
Weisner et al in 2010 conducted a randomized control trial on 10patients with no baseline differences. The trial was a split mouth study with grafting procedure on one site and non-graft tissue on the other site. The study showed a higher pink esthetic score in the grafted site. A parallel group study by Lorenzo et al in 2011 with 12 patients done with sub-epithelial tissue graft and Xenogeneic graft provided the same thickness of keratinised mucosa after the treatment and there was no significant difference in the amount of gingival recession in these techniques as they showed the same amount of recession – 0.4mm and 0.5mm respectively. The amount of soft tissue gain in autograft was 2.3mm and xenogenic graft material was 2.4mm. A study conducted by Abdel Salem in 2002 to determine the predictable esthetic outcome was based on the use connective tissue grafts. The treatment outcome was good but due to lack of measured data, the study could not be included. Simion et al in 2012 conducted a study on 6patients in the maxillary anterior esthetic zone. The study included the use of xenogenic graft infused with rhPDGF-BB and the follow up was for 3.5years. The mean gain in the soft tissue volume were measured in the apical, central and occlusal aspect in the implant region which were 0.87 ± 2.13 mm, 2.14 ± 3.27 mm, and 0.35 ± 3.20 mm respectively.
Individual studies for xenogenic and autografts showed significant improvement and esthetic result, this aided the comparative study of the graft procedures and its treatment outcome. Lorenzo et al in 2012 conducted a control trial in 24patients. This study was a comparative study between sub-epithelial connective tissue and xenogenic graft. The mean gain for the connective tissue graft was 2.33mm and 2.30mm for the xenogenic graft. This showed very less significant gain in the soft tissue volume. It is seen when we use a Xenogeneic or alloderm graft material, the patient compliance is better and the amount of surgical procedure and the time is also reduced as the need to take graft from the donor site is eliminated. The use of allograft – soft tissue palatal grafts is the most widely and effectively used method as it provides the graft with excellent vasculature and nourishment. This avoids the possibility of tissue rejection or denuding of the surface. The possibility of any significant amount of recession is avoided by properly determining the required adequacy of the soft tissue by evaluation the soft tissue defects. Free gingival grafts and sub-epithelial connective tissue grafting techniques are the most effectively used but it is technique sensitive and yields very good esthetic outcome. Several techniques have been suggested for soft tissue augmentation which is decided only based on the amount of defect and the requirement to restore its esthetic morphology. The evaluation of the best surgical technique for soft tissue augmentation is based on the individual peri-implant environment.

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