Original study - ZZI 02/2011

Evaluation of the influence of preoperative factors
on soft tissue consolidation around single tooth implants
in the esthetic zone – A pilot study

Despite numerous single case reports, there are so far no evidence-based data on incision techniques, flap design and indication for soft tissue augmentation [5, 9]. The present study found highly significant associations between the exposure concept and PES on univariate analysis. On multivariate analysis, however, a significant influence could not be confirmed, possibly because of the small number of cases. Surgical procedures such as papilla reconstruction and palatal roll, which can increase the volume of the soft tissue, achieved good esthetic outcomes in our study. Lower scores were assigned for implants that were uncovered by a simple crestal incision. The causes of this were a reduced soft tissue level and incomplete papillae, especially in the case of neighboring implants in the premolar area. In eleven patients (22.4 %), exposure was by means of an apically positioned flap and free mucosal graft (FMG) from the hard palate. The aim of this technique is to create a minimum circular periimplant width of fixed keratinized gingiva of 2–3 mm [2]. Although there is insufficient evidence according to recent review articles [7], it is assumed that oral hygiene is improved by the fixed keratinized gingiva and plaque accumulation is reduced [27]. This ensures the long-term esthetic and functional result. A systematic review article by Thoma et al. found that an average widening of the zone of fixed keratinized gingiva by 4.49 mm can be achieved by vestibuloplasty/apically positioned flap in combination with a free mucosal graft from the hard palate compared with untreated controls [29]. To minimize problems of donor site morbidity, allogeneic and xenogeneic substitute materials have been introduced and tested [34]. Compared with the “gold standard” of the autologous mucosal graft, however, there was a significantly lower gain of fixed keratinized gingiva and markedly greater shrinkage on follow-up [15]. Studies by our research group have shown that this shrinkage after use of allogeneic materials can be attributed to increased and prolonged recruitment of macrophages in the early healing periods with subsequent fibrocontractile tissue remodeling [16]. From the esthetic aspect, the FMG outcomes are usually unsatisfactory as a result of color mismatch and should, in consequence, be employed only in the mandible, posterior maxillary region or in wearers of overdentures [20].


Within the limitations of a pilot study employing a small sample size, it was confirmed that insufficient hard and soft tissue represents the greatest challenge for the implantologist. Current developments in minimally invasive hard and soft tissue management techniques might help to enhance the esthetic outcomes for these patients in the future.


Conflict of interests: none stated

Correspondence address

Cornelia K. Müller

Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie/Plastische Chirurgie

Universitätsklinikum Jena

Erlanger Allee 101, 07747 Jena

Tel.: +49 (0) 3641 / 9 323666

Fax: +49 (0) 3641 / 9 323630

E-Mail: cornelia.mueller1@med.uni-jena.de


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