80Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012
Management Of Soft Tissue Esthetics In
Dr. Ajay Vikram Singh
Dr. Ajay Vikram Singh, after completing his BDS, received PG certificate training in Implantology from India followed by advanced level implant
training at different centers and continuing education implant programmes in USA. He is an internationally acclaimed mentor, speaker and
researcher in the field of implantology. He has spoken as the key note speaker in different national and international implant conferences. Besides
being an active member of many prestigious implant associations, he is a Fellow and Diplomate of International Congress of Implantology. He
has been running basic to advanced level implant training programmes at his Implant Center, at Agra since 2005 and has trained many national
as well as international dentists with his implant skills. Dr. Ajay can be reached at – email@example.com
Dr. Sunita Singh
Dr. Sunita Singh, after completing her BDS received a lot of continuing her education in Esthetic And Implant Dentistry and Fixed Orthodontics
at different Centers in India and USA. She has attended and presented her skills in many national and international Dental Conferences. She
has taken special training in Cosmetic Dentistry at the Continuing Education Programme at Washington University (USA). She is a member
of American College of Prosthodontists in USA. She is an active member of Indian Academy of Aesthetic and Cosmetic Dentistry as well as
Academy of Oral Implantology. She has been practicing with Dr. Ajay since 2003 at Dr. Ajay Dental Clinic and Research Center, Agra.
The successful use of dental implants to replace missing teeth has
been one of the most popular, exciting and evolving areas of clinical
dentistry. When implants are thought as a treatment option, treatment
planning has become more complex for the dental practitioner and
an interdisciplinary team approach is recommended to achieve a long
term esthetic as well as functional outcome in the implant restorations.
Failure to demonstrate such an approach might lead to undesirable
esthetic and functional implant complications. The long term clinical
and esthetic success of an implant retained restoration is determined
by stable peri-implant soft tissue morphology in hormone with the
surrounding soft tissues and natural dentition. In addition to successful
osseointegration of the implant, the surrounding soft tissues play an
important role in the vascularization of the underlying bone. Insufficient
soft tissue causes improper nutrient supply the underlying peri-implant
bone and may lead to crestal bone resorption after implant is restored
in function. Proper gingival architecture is especially important in the
implants placed in the esthetic region. Thorough treatment planning
and knowledge of the specific phases of inflammatory and regenerative
processes associated with wound healing are essential for predictable
esthetic results. Preoperative deficiency of the soft tissue often mandates
the extensive soft tissue management, mobilization and augmentation
procedures to obtain the esthetics around the implant restorations.
Various soft tissue management and augmentation techniques are
applied to obtain adequate esthetic emergence profile of the implant
restoration with sufficient keratinized gingiva. However, efforts should
be made to preserve the existing esthetic soft tissue profile by implant
placement with minimal soft tissue injury during implant insertion
and uncovering and also by supporting the soft tissue architecture
using a provisional prosthesis during subgingival or open healing of
the implant. Immediate implantation in the extraction socket with an
anatomical provisional restoration, which is immediately fixed after the
implant insertion to support the soft tissue profile of the socket, should
be practiced in the esthetic region. Optimizing implant placement,
particularly position and angulation, allows the clinician not only to
approximate the form of the original dentition, but to create an esthetic
soft-tissue contour and provide a long-term function.
• Favorable and unfavorable soft tissues around the implant
The keratinized and stable soft tissue with thick biotype is the
favorable tissue for long term implant health as it is more
resistant to chemical and mechanical injuries, muscle pull, etc.
(Fig. 1) and thus prevent the occurrence of peri-implantitis and
Fig. 1 Thin, non keratinized and mobile marginal soft tissue is less resistant to
the muscle pull and recedes, which may result in recurrent peri-implantitis and
subsequent peri-implant crestal bone loss.
82Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012
crestal bone loss. In short, for the long term health of the implant
restoration minimum 2-3 mm of thick, keratinized and attached
marginal soft tissue should be present. Efforts should be made
to preserve the existing keratinized tissue at the implant site
by closely evaluating the type of soft tissue biotype and accordingly
planning the incisions and implant placement protocols to
minimise the loss or recession of the favorable marginal soft
tissue. A thick, keratinized and non mobile marginal soft tissue
offers several advantages such as protect the peri-implant tissues
from injury and infection, resist the pull of muscles, resistant to
the marginal soft tissue recession, better plaque control, adequate
soft tissue esthetics, etc. (Fig. 2)
Soft Tissue Biotypes
Gingival thickness, its morphology, presence of interdental papilla
and the osseous architecture at the site are all determining factors
in periodontal biotyping and can influence surgical approaches and
healing in the field of implantology. Ochsenbein & Ross described
healthy periodontal tissues by the biotype categories of thin scalloped
(thin gingival tissue, long papillae and thin scalloped bone) and
thick flat (thick gingival tissue, short and wide papillae and thick, flat
bone). Olsson & Lindhe further categorized the periodontium based
on the associated tooth form and susceptibility to gingival recession.
The triangular tooth form is associated with a scalloped and thin
periodontium. The contact area for the triangular tooth shape is at
the coronal third of the crown, supporting a long and thin papilla.
The squared tooth combines with a thick and flat periodontium. The
contact area for the square tooth shape is at the middle third of the
crown, supporting a short and wide papilla. Periodontal biotyping
affects practically all periodontal surgical procedures, including crown
lengthening, implant placement and tissue grafting. A thin periodontal
biotype is the more technique-sensitive and can post-treatment, give
rise to gingival recession or black triangle formation. An implant placed
in a site with a thin periodontal biotype may develop mucosal recession
or bluish color changes.
Soft Tissue Management
Peri-implant mucosal height essentially follows the crest of the
alveolar bone; however, the determining factors in inter implant
papilla development are complex and may not be fully controlled by
implant design features or surgical interventions. Although bone height
and thickness are major determinants of soft tissue height, factors
such as tooth morphology, location of the interdental contact point
and arrangement and quality of soft tissue fibers can also influence
soft tissue appearance. Lack of dento-gingivo-alveolar circular,
semicircular, transeptal, interpapillary and intergingival fibers around
implants constitutes a major obstacle in soft tissue appearance and
management around implants. The absence of inter implant papillae
causing an inter-implant black triangle continues to be a significant
problem in dental implant esthetics. The type of provisional prosthesis
used during the healing period is critical for optimal healing. The
design of the provisional restoration should be based on thorough
diagnostic information and provide minimal post surgical irritation
and pressure on soft tissues. A proper interim prosthesis can provide
valuable suggestions about the esthetic appearance of the definitive
restoration. The thickness, height and contour of the facial alveolar
plate can significantly affect the labial position, the facial expression
and the smile. There is a wide range of variation in the morphology of
the alveolar plate. A dynamic balance between functional forces and
existing alveolar bone shape sculpts the alveolar bone morphology.
The housing of a standard 3.75–4mm diameter implant requires 6 mm
of bone in the bucco–lingual dimension and 5–6 mm of bone in the
mesio–distal dimension. Both thickness and height of the facial alveolar
plate are influenced by implant angulation. A lingual implant inclination
is associated with a thick and flat facial alveolar bone that provides soft
tissue support in a more coronal position than normal. A labial implant
inclination is associated with a thin and scalloped facial alveolar bone
that often is located in an apical position. Lingually inclined anterior
implants provide a thicker coronal portion of the facial alveolar plate
and counteract a tendency to peri-implant bone resorption. Vertical
and horizontal enlargements of the facial alveolar plate prior to implant
placement can be critical for the long-term maintenance of soft tissue
height. Limitations in bone quantity in the mesio–distal dimension may
be caused by root position of adjacent. Tooth morphology is related
to the periodontal biotype and this phenomenon is most evident in
the anterior esthetic zone of the mouth. The triangular shaped tooth
is linked to a thin, scalloped periodontium (Biotype I). In this biotype,
the interproximal contact area is located in the coronal one-third of
the crown and is associated with a long and thin papilla. The square-
shaped tooth is connected to a thick and flat periodontium (Biotype
II). The interproximal contact area is located at the middle one-third
of the crown and supports a short, wide papilla of teeth. Orthodontic
movement used to change the root position can provide the necessary
space for implant insertion. A reduced horizontal distance between a
tooth and a neighboring implant may adversely affect the bone level
at the tooth side.
Fig. 2 A thick, keratinized and stable marginal soft tissue offers several
advantages such as protect the peri-implant tissues from injury and infection,
resist the pull of muscles, resistant to the marginal soft tissue recession, better
plaque control, adequate soft tissue esthetics, etc.
84Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012
Case Report - 1 Soft Tissue Preservation In Case Of Immediate
Implantation In Esthetic Region
Immediate implantation cases have been and continue to be the
challenge in providing immediate and long term esthetic and functional
implant restorations. The conventional delayed implant placement may
result in loss of hard and soft tissue architectures of the socket as part
of natural healing processes. The unsupported papillae get lost during
the healing phase of the socket and often result in flat soft tissue at the
ridge crest and black triangles around the implant prosthesis. Immediate
implantation with immediate restoration supports the present soft tissue
architecture and also guides the soft tissue to take a desired shape
to provide final restoration with esthetic emergence. But immediate
implantation with immediate functional or nonfunctional restoration is
a technique sensitive procedure as it needs the implant positioning at
the ideal place in the socket, achieving initial stability of the inserted
implant which is adequate for immediate restoration, grafting of peri-
implant socket spaces and immediate fabrication and placement of a
provisional restoration of the desired anatomic shape (Figs. 3 to 8).
Fig. 3 A 40 year male patient presented with mobile tooth no. 21. (a) The dental
radiograph revealed the root fracture with some amount of vertical bone resorption
(b) For minimal invasive flapless implant placement, the site is planned with CT
cross section to place the implant at the ideal position and axis (c) The longest
possible implant with its placement slightly towards palatal position to provide room
for the regeneration of thick volume of hard and soft tissue on the facial aspect and
to stabilize the implant in the high density nasal floor to achieve adequate primary
stability so that the implant can immediately be restored, was planned.
Fig. 4 The tooth and its fractured root are extracted out using periotomes and
luxators with minimal trauma to the bone and soft tissue (a). The osseous
topography was evaluated, all the granulation tissue was currated out of the socket
and socket is disinfected using clindamycin to kill residual pathogens. The root
dimensions are measured using calipers to decide the appropriate implant size.
The implant osteotomy is prepared into the socket, slightly palatal to the long axis
of the socket using side cutting Lindemann drills (b) An implant with dimensions of
4.2 X 16 is placed at the correct three dimensional position (c&d)The implant apex is
stabilized in the high density nasal floor to achieve adequate bone implant contact
percentage and primary stability (more than 35Ncm) of the implant. The implant
platform is placed 2-3 mm apical to the cemento-enamel junction of the adjacent
teeth and palatal to the imaginary line joining the facial aspects of the CEJ of two
adjacent teeth. This provides adequate amount of tissue for esthetic emergence of
the implant prosthesis.
Fig. 5 The periimplant socket spaces are grafted using a mixture of HA (70%) and ß
Tcp (30%) bone substitute without using any barrier membrane (a). An appropriate
abutment is selected, prepared and composite is build up over its surface in the
anatomical shape of natural tooth at cervical part to provide adequate support to
the marginal soft tissue and papillae and also to prevent the loss of graft from the
site (b). The abutment is screwed onto the implant (c).
86Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012
Fig. 6 A provisional prosthesis is fabricated onto this abutment in mouth using
custom poly crown. A screw hole is prepared through the crown to access the
connection screw (a). The provisional crown along with abutment is removed from
the implant and screwed to the analog to shape the provisional crown (b and c).
(b). At this stage transferring the same soft tissue profile from the mouth to the
working cast with the implant impression is paramount to fabricate the final crown
with same anatomic shape at the cervical half. Thus the closed tray impression
transfer abutment is inserted over the implants and simultaneously the soft tissue
socket spaces are filled with flow composite (c). The impression is made using a
silicon material and this impression abutment along with composite remain bonded
to it is transferred to the impression with same orientation, which results is the
transfer of the exactly same soft tissue profile to the working cast. This helps the
technician to understand the anatomical shape on the soft tissue and accordingly
he can fabricate the implant restoration with an esthetic emergence.
Fig. 8 Appropriate final abutment is selected and
prepared in the laboratory to provide the room for the
ceramic buildup. The abutment is screwed over the
implant (a) and final crown is fixed using the dual cure
resin luting cement (b). The preservation of exact soft
tissue profile can be seen in this case which resulted in
the esthetic emergence for the implant prosthesis. Post
loading radiograph (c).
Fig. 7 The provisional crown of the anatomical shape is screwed over the implant
immediately after the implant placement (a). The anatomic provisional crown has
maintained the scalloped soft tissue architecture of the socket, as can be seen after
crown is removed for prosthetic phase after 6 month healing of the implant
Dr. Ajay Vikram Singh is a keynote speaker at
Famdent Show Delhi 2012
87Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012
Soft Tissue Management in Implantation at Healed Site
• Soft tissue management - The soft tissue management to
achieve the esthetic emergence and esthetic papillae around the
implant restoration is a challenge for the implant dentists in cases
of healed sites with lost papillae. Careful evaluation of the
soft tissue, meticulous treatment planning, ideal implant
positioning, crafting the soft tissue to the desired shape and
careful dealing with soft tissue during the implant placement and
restoration procedures result in achieving the desired esthetic
results (Fig. 9 a-d).
• The soft tissue grafting - In various cases in day to day
implant practice, the soft tissue remains deficient at the implant
site, where it may require various type of soft tissue augmentation
(epithelialized connective tissue or only connective tissue)
procedures to generate the thick, keratinized and attached
marginal soft tissue around the implant restoration, which not
only provides the esthetic emergence to the implant restoration but
also is more resistant to the muscle pull, mechanical and chemical
injuries, recession and peri-implantitis (Fig. 10 a-d). Depending on
an individual case, the soft tissue grafting procedure can be
performed before implant placement, at the time of implant
insertion, at the time of uncovering or after the implant restoration
but usually it is preferred to be done in most cases at the time of
The presence of a thick, stable and keratinized marginal soft tissue
is paramount to achieve the esthetic emergence of the implant
restoration as well as for the long term success of the esthetic implant
restorations. Efforts should be made to preserve the existing soft tissue
at the implant site. Moreover, the presence of compromised soft tissue
at the implant site requires the soft tissue augmentation procedures
to regenerate the favorable marginal soft tissue at the implant site. At
the implant site where the keratinized and stable soft tissue is present
Fig. 9 The single piece implant (3.75X15) is placed at the maxillary canine site
following the minimal invasive implant placement surgery. The site was edentulous
since few years, thus lost the papillae and now regenerating lost papilla around
the implant restoration is the challenge in such cases. The implant has achieved
adequate primary stability required for non functional restoration. The implant
abutment is prepared in the mouth (a) and restored using a provisional crown
which is kept well out of occlusion to avoid occlusal forces during implant healing.
The flap is sutured around this provisional crown (b). The provisional crown of
anatomical shape in the cervical half guided the soft tissue to take the esthetic
shape during implant healing. The removal of provisional crown after 6 weeks has
resulted in the formation of esthetic scalloped soft tissue profile (c). The final crown
at place is showing the acceptable soft tissue emergence and papillae regeneration
around the implant restoration (d).
Fig. 10 The site with thin, mobile, and non keratinized soft tissue with the see
through of the implants cover screws before the implant uncovering (a). Uncovering
and restoration of these implants without performing soft tissue augmentation
procedure may result in compromised marginal soft tissue around the implant
restoration which may cause problems like soft tissue recessions, recurrent peri-
implantitis and crestal bone resorption. A full thickness epithelialized connective
tissue graft is harvested from the patient’s palate and sutured at the site at the
stage of implant uncovering following all the specific protocols of recipient site
preparation, and soft tissue grafting (b and c). Regeneration of thick, keratinized
band of marginal soft tissue can be seen 4 weeks after the soft tissue grafting
(d). This kind of tissue will not only provide esthetic emergence to the implant
restoration but is more resistant to muscle pull, recessions, and peri-implantitis.
88Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012
but is showing some kind of soft tissue defect in ridge morphology,
the only connective tissue graft harvested from the palate is placed
after elevating the partial thickness flap. It enhances the connective
tissue thickness and ridge morphology around the implant restoration.
In cases where the thin, mobile and non keratinized marginal tissue
is present, the partial or full thickness epithelialized soft tissue graft is
harvested from the palate or the edentulous ridge area and grafted at
the site after elevation of the partial thickness flap and proper recipient
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