This document discusses soft tissue procedures related to dental implants. It begins with the anatomy and biology of peri-implant soft tissue, noting similarities and differences to periodontal tissue. Clinical examination factors for soft tissue are described, including lip line, smile line, gingival biotype, and papilla evaluation. Surgical procedures for soft tissue are outlined, including timing of the procedures in relation to implant placement. Specific techniques discussed include tissue punch, palatal pedicle flaps, and free palatal and connective tissue grafts. Indications for these procedures are provided to augment soft tissue for dental implants.

1. 19. Soft Tissue Procedures
Moustafa H El-Ghareeb BDS MS
The Surgical Implant Center
UCLA School of Dentistry
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2. Anatomy & Biology
of Peri-Implant Soft Tissue
Similarities betwee
periodontal & peri-implant ST:
! Oral epithelium
! Sulcular epithelium
! Junctional epithelium
Differences in peri-implant
ST include:
! Lack of CT attachment
! Hypovascular,
hypocellular CT zone adjacent to the Sclar AG, 2003
implant
! Absence of periodontal ligament blood
supply

3. Clinical Exam
The systematic evaluation of the esthetic implant patient
starts with assessment of the underlying hard tissue
Hard Tissue Assessment:
Esthetic soft tissue results rely
on good bony foundation
!
!
!
The height of the alveolar crest at
adjacent teeth or in between 2 dental
implants is responsible for supporting
the interdental papilla
The height and thickness of the facial
bone wall is responsible for
supporting the overlying marginal
gingiva & provides soft tissue framing
In order to obtain good esthetic ST
outcome, hard tissue defects (vertical
&/or horizontal) should be
reconstructed prior to implant
placement
Crestal Bone
Buser D, 2004
Facial bone
wall

4. Clinical Exam
Facial & ST Assessment:
Upper lip line:
! At rest, relaxed, & fully
!
!
!
!
animated
Determine how much of teeth &
soft tissue is visible during
maximal smile
Most common tooth/gingiva to
lip relationship on maximal
smiling reveals the entire
clinical crowns & interdental
papillae
This relationship determines
what therapeutic modalities will
be needed to obtain an esthetic
result
A high esthetic result is crucial
with significant gingival display
High Smile Line
Low lip line

5. Clinical Exam
Number of teeth visible during smiling
! Most common display in
the population includes the
second bicuspid
! Next common is equally
divided between first molar
& first bicuspid
! Clinical relevance:
significant display of
posterior dentition &
gingival tissues expands
the esthetic zone beyond
the anterior region (sites
#6-11)

6. Clinical Exam
Partially Edentulous
Mucosal characteristics:
! Assess amount of keratinized mucosa
! Ideally ≥ 3 mm of keratinized mucosa
around implants
! Attached mucosa is preferable but
unattached has been successful when
oral hygiene is adequate (MericskeStern 1990)
! Attached mucosa :
1. Provides a “prosthetic-friendly”
environment
2. Facilitates OH maintenance required for
long-term success
3. Resists recession
4. Maintains predictable levels over time
5. Enhances esthetic blending
Fully Edentulous

7. Clinical Exam
Gingival biotype:
Thick blunted:
ü Resists recession & reacts to
surgical & restorative insults with
pocket formation
Thin scalloped:
Thick Blunted
ü Attached soft tissue is minimal
ü Bony dehiscence & fenestration
defects characterize the
underlying osseous structure
ü Reacts to surgical or restorative
interventions with ST recession,
apical migration of attachment &
loss of underlying alveolar
volume
Thin Scalloped

8. Clinical Exam
Gingival margin/outline:
• Sinuous versus
Straight pattern
Sinuous pattern
straight gingival
pattern
• Symmetry, asymmetry
distracts from the
esthetic appearance of
the patient’s smile
Discrepancy in gingival margin positions

9. Clinical Exam
Interdental papilla evaluation: Palacci classification (Palacci 2001
! Class I: Intact or slightly
reduced papilla
! Class II: Limited loss of
papilla
! Class III: Severe loss of
papilla
! Class IV: Absence of papilla
Papilla score (Ryser et al
2005):
Palacci 2001
I
II
• 4=papilla fills the entire
interdental space
• 3=>50% of the space filled
• 2=<50% of the space filled
• 1=no papilla present
III
IV

10. Soft Tissue Surgical Procedures
Timing
! Before dental implant placement
! At the time of dental implant placement
! At the time of second stage surgery
! After implant restoration (least desirable)

11. Soft Tissue Surgical Procedures At
Time of Second Stage Surgery
!
!
ü
ü
ü
ü
ü
ü
Assess amount of
keratinized mucosa and
proceed accordingly
Different techniques in
different situations:
Tissue punch or Scalloping
Midcrestal incision
Crestal incision but more
palatal
Full thickness flap
Partial thickness flap with
apical repositioning
Pedicle rotational flaps
(papilla regeneration)

12. Soft Tissue Surgical Procedures At Time
of Second Stage Surgery
Tissue Punch & Scalloping:
! Indicated only when the
volume & architecture of the
peri-implant ST are ideal
(i.e. wide thick band of
keratinized ST)
! Orient the punch more
palatally to preserve excess
ST volume on the facial
aspect

13. Soft Tissue Surgical Procedures At
Time of Second Stage Surgery
ST punch cannot be used with limited amount
of keratinized mucosa

14. Soft Tissue Surgical Procedures At Time
of Second Stage Surgery
ST punch & scalloping techniques
Scalloping
technique
Soft-tissue punch
Punch & scalloping
technique

15. Soft Tissue Surgical Procedures At Time
of Second Stage Surgery
Full thickness flap technique
Reverse soft-tissue
architecture
Full-thickness flap technique
Full-thickness flap
technique
H incision (full thickness flap)

16. Soft Tissue Surgical Procedures At
Time of Second Stage Surgery
Palacci papilla regeneration technique
Palacci 2001
Can be performed only when adequate amount of keratinized mucosa is available
Palacci double pedicle flaps

17. Soft Tissue Surgical Procedures At
Time of Second Stage Surgery
Palacci papilla regeneration technique
Semi-lunar bevel incision
Pedicle flaps
Rotation of pedicle flaps
Palacci, 2001

18. Soft Tissue Surgical Procedures At Time
of Second Stage Surgery
Partial thickness flap with apical repositioning:
! Can be utilized to increase
zone of attached tissue with
limitations secondary to
contracture
! Apical repositioned flaps are
sutured to the periosteum
(arrows)
! A soft lined CD is provided to
protect site, improve patient
comfort & minimize relapse
Narrow zone
of keratinized
mucosa
Sharp
supra-periosteal
dissection
Partial thickness flap
Is apically repositioned
& sutured to periosteum

19. Soft Tissue Surgical Procedures
Free palatal & CT grafts
Preparation of recipient site:
Management of donor tissue:
Ensure adequate vascularity to
support the graft (initial survival is
by plasmatic diffusion )
!
Provide a means of rigid
immobilization of the graft (mobility
disrupts the newly forming
circulatory support)
!
Prepare uniform surface for intimate
graft adaptation
!
Obtain hemostasis
ü hemorrhage prevents intimate
adaptation of the graft to underlying
bed through fibrin layer
ü Fibrin attaches graft to bed &
provides for the plasmatic diffusion
!
!
!
!
Harvest graft of adequate size to
take advantage of peripheral
circulation
Ensure a uniform graft surface for
adaptation of recipient site
Ensure adequate thickness to
obtain desired volume
augmentation & for survival over
avascular surfaces

20. Soft Tissue Surgical Procedures
Indications of free palatal
grafts:
!
!
ST augmentations in non
esthetic areas
To increases the zone of
keratinized tissue around
implants
Note distinct margins & poor esthetic
blending with surrounding tissue

21. Soft Tissue Surgical Procedures
Free palatal Grafts (free gingival
grafts):
!
Donor tissue is sized to recipientsite dimensions
!
Anterior incision is beveled to
facilitate localization of appropriate
plane of dissection
!
A thick split-thickness graft
approaching full thickness is
preferred (1.25-1.75 mm) when
abutment coverage is desired
!
Primary contraction is negligible
with palatal grafts
!
Secondary contraction is rarely a
problem with thick split thickness
grafts.

22. Soft Tissue Surgical Procedures
Free palatal graft harvest:
!
Apply gentle traction with tissue
forceps
!
A uniform graft is harvested with
sharp dissection
!
Hemostasis is achieved with
electrocautery
!
The donor site is dressed with
absorbable collagen
!
A palatal stent or a soft lined
maxillary CD is provided to
protect site & improve patient
comfort
Donor site 4 weeks after surgery
Adequate hemostasis achieved

23. Soft Tissue Surgical Procedures
Free palatal graft
Atrophic MN with thin
band of attached ST
Immobilization of graft
at recipient site
Creation of a uniform periosteal
recipient site
One week postoperative:
Superficial epithelial
sloughing & initial revascularization
One-year postoperative view
Note secondary contraction (arrow)

24. Soft Tissue Surgical Procedures
Indications of subepithelial CT
grafts:
!
!
!
!
!
ST augmentation in esthetic
areas due to superior color
match & esthetic blending
To provide a zone of attached
non mobile ST around
implants
? The underlying CT will
determine the character of the
overlying epithelium
To enhance ST contours
To reconstruct missing ST
volume defects

25. Soft Tissue Surgical Procedures
CT graft harvest:
!
!
!
!
!
Blade is oriented parallel to surface of
palatal tissue
CT graft is harvested
Absorbable collagen dressing is used
to obliterate dead space
Donor site is closed primarily
A palatal stent may be used to support
palatal tissue & prevent hematoma
formation

26. Soft Tissue Surgical Procedures
Subepithelial CT graft recipient site:
!
Has dual blood supply to support
graft revascularization (from
periosteum & partial thickness
cover flap or periosteum & bone
surface)
Partial thickness MP flap reflection
CT graft sutured to underlying periosteum
Full thickness MP flap reflection
CT graft sutured to the periosteal side of the flap
Tunneling technique

27. References:
!
!
!
Sclar AG. Soft tissue and esthetic considerations in implant
therapy. Quintessence, 2003
Palacci P. Esthetic implant dentistry: Soft and hard tissue
management. Quintessence, 2001
Buser D, Martin W, & Belser UC. Optimizing esthetics for
implant restorations in the anterior maxilla: Anatomic and
surgical considerations.
Int J Oral Maxillofac Implants. 2004;19 Suppl:43-61