Volume 87 • Number 2

Review
The Effect of Subepithelial Connective Tissue Graft
Placement on Esthetic Outcomes After Immediate
Implant Placement: Systematic Review
Chun-Teh Lee,*§ Chih-Yun Tao,† and Janet Stoupel‡

Background: Immediate implantation, despite many advantages, carries a risk of gingival recession,
papilla loss, collapse of ridge contour, and other esthetic complications. Soft tissue graft placement com-
bined with immediate implantation may be used to reduce these concerns. This review aims to systemat-
ically analyze clinical esthetic outcomes of the immediate implant combined with soft tissue graft (IMITG).
Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guide-
lines for systematic reviews were used. The electronic search was conducted using MEDLINE (PubMed),
EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) from January 1980 to October
2014. Quality assessments of selected articles were performed. Mid-buccal gingival level, interproximal
gingival level, facial gingival thickness, gingival ridge dimension, and width of keratinized gingiva were
the esthetic outcomes reviewed. Weighted mean difference of mid-buccal gingival level (WDBGL), pa-
pilla index score (WDPIS), and width of keratinized gingiva (WDKG) between initial and last measure-
ments were calculated. Other esthetic outcomes were assessed by the descriptive analysis.
Results: Ten studies with a minimum of 6-month follow-up were included, and reported esthetic out-
comes were analyzed. Mid-buccal gingival level (WDBGL, 0.07 mm; 95% confidence interval [CI] = -0.44
to 0.59; P = 0.12) and interproximal gingival level did not significantly change after IMITG (WDPIS in the
mesial site, 0.31; 95% CI = -0.01 to 0.64; P = 0.06; and WDPIS in the distal site, 0.29; 95% CI = -0.06 to
0.65; P = 0.11). Width of keratinized gingiva significantly increased after IMITG (WDKG, 1.27 mm; 95%
CI = -0.08 to 2.46; P = 0.04). Facial gingival thickness and gingival ridge dimension could be increased
after IMITG.
Conclusions: Because of the heterogeneity and limited number of selected studies, no conclusive
statement could be made regarding the benefit of IMITG on esthetic outcomes. More randomized con-
trolled trials are needed to provide definite clinical evidence. J Periodontol 2016;87:156-167.
KEY WORDS
Dental implants; esthetics, dental; evidence-based dentistry; periodontics; treatment outcome.

* Department of Applied Oral Sciences, Forsyth Institute, Cambridge, MA.

† Department of Periodontics and Dental Hygiene, The University of Texas Health Science Center at Houston, Houston, TX.
‡ Department of Dentistry, School of Dentistry, National Taiwan University, Taipei, Taiwan.
§ Division of Periodontics, Section of Oral and Diagnostic Sciences, College of Dental Medicine, Columbia University, New York, NY.

doi: 10.1902/jop.2015.150383

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J Periodontol • February 2016 Lee, Tao, Stoupel

‡10 human participants per study group; 4) at least one

I
mmediate implantation, despite numerous benefits,
does not preclude loss of the buccal bone,1,2 gingi- tooth per participant in the maxillary or mandibular
val recession (GR),3 or ridge dimensional change.4,5 premolar-to-premolar span replaced by an IMITG; and
Bone grafts, barriers, and soft tissue grafting have been 5) one or more of the following outcomes was reported
used separately or together to minimize gingival and at baseline and at least at 6-month follow-up: BGL and
ridge contour changes after immediate implantation. IGL, FGT, gingival RD, or KG.
Autogenous soft tissue grafting has been utilized in
Search Strategy
varied clinical procedures.6-11 A number of studies have
The electronic search was conducted in MEDLINE
demonstrated clinical superiority of autogenous soft
(PubMed), EMBASE, and Cochrane Central Register
tissue grafts compared with the available substitutes,
of Controlled Trials (CENTRAL) from January 1980 to
such as acellular human dermis and xenogenic col-
October 2014. An additional search was performed in
lagen matrix, used in procedures of root coverage and
peer-reviewed journals. Moreover, the reference lists
extension of keratinized gingival width.12-14
of selected articles were screened to find additional
In implant therapy, soft tissue grafts are used in
publications that might fit the selection criteria. The
ridge reconstruction,15 coverage of crown margins or
search methods in the databases and the list of journals
implant surfaces,16,17 to seal extraction sockets after
are described in supplementary Appendix 1 in online
immediate implant placement, and to increase width
Journal of Periodontology.
of keratinized gingiva (KG).18-22 Combination ther-
apy of soft tissue and osseous grafting with or without Quality Assessment
a barrier in conjunction with immediate implantation RCTs were assessed by the Cochrane Collabora-
has been proposed23-25 to address vertical and hor- tion tool.37 ‘‘High risk of bias,’’ ‘‘low risk of bias,’’ or
izontal ridge dimensional reduction, GR, and to in- ‘‘unclear risk of bias’’ was assigned to each assess-
crease KG.26,27 These procedures primarily aim to ment item. Other selected studies fulfilled the criteria
improve the esthetic outcomes after immediate im- of cohort studies. 38 The Newcastle-Ottawa scale
plant placement. (NOS) was used to assess the methodologic quality
Some studies report clinical benefits of gingival of the retrospective or prospective cohort studies.39
level maintenance, increased KG, and gingival thick- The assessments were performed by two examiners
ness after immediate implantation combined with soft (C-TL, C-YT); interexaminer agreement k coeffi-
tissue graft (IMITG).24,28,29 Others demonstrate suc- cient was calculated. Discrepancies between the two
cessful esthetic outcomes of immediate implantation examiners in quality assessment were resolved via
without soft tissue grafting.30-33 Lack of consensus discussion.
regarding the advantages of esthetic outcomes with
Grading the Body of Evidence
IMITG therapy versus immediate implantation alone
Quality-of-evidence (risk of bias in reported out-
led to this systematic review.
comes, inconsistency of outcomes among studies,
MATERIALS AND METHODS indirectness of reported outcomes, imprecision of
reported outcomes, and potential publication bias)
This systematic review was performed by following pre-
assessment was based on the Grading of Recom-
vious recommendations34 and the PRISMA (Preferred
mendations Assessment, Development and Evaluation
Reporting Items for Systematic Reviews and Meta-
(GRADE) system. 40,41 Two authors (C-TL, C-YT)
Analyses) principles.35
evaluated the studies independently and reached
Focused Question agreement by discussion.
The focused question was proposed by following the
Data Extraction and Data Synthesis
PICOS (Participant, Intervention, Comparison, Out-
All articles were screened by two authors (C-TL,
come, Study Design) principle:35,36 What are the es-
C-YT). The same cohort studies with the longest follow-
thetic outcomes (mid-buccal gingival level [BGL] and
up were included. Data were extracted independently
interproximal gingival level [IGL], facial gingival thick-
with a custom form. Accuracy of extracted data were
ness [FGT], gingival ridge dimension [RD], and KG)
confirmed by another author (JS). Questions regarding
of single IMITG compared with single immediate im-
studies were addressed to the article authors.
plant placement alone in the retrospective or pro-
Following outcomes were chosen for analysis: 1)
spective studies with at least 6-month follow-up?
BGL; 2) IGL; 3) FGT; 4) gingival RD; and 5) KG.
Study Selection Criteria Because none of the studies included in this review
The following criteria were used for selection: 1) pub- reported all the outcomes of interest, the datasets of
lications in English; 2) randomized controlled trials each outcome are extracted from respective studies. If
(RCTs) or non-randomized controlled trials, prospective meta-analysis of an outcome could not be conducted
or retrospective cohort studies, and case series only; 3) because of a small number of qualified studies, study

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Immediate Implant Combined With Soft Tissue Graft Placement Volume 87 • Number 2

were performed using statistical

software.i Statistical significance
was defined as P <0.05.

RESULTS
Initial electronic data and journal
search produced 263 articles.
Twenty-nine articles qualified for
additional review based on titles
and abstracts. Nineteen articles
were excluded because of incom-
plete data reporting or unqualified
study design (see supplementary
Appendix 3 in online Journal of
Periodontology). Ten articles (eight
cohort studies and two RCTs) cor-
responded to the selection criteria
(Fig. 1). Follow-up periods ranged
from 6 to 25.8 months (Table 1).
A total of 217 implants are in-
cluded in this review. Two hundred
sixteen implants survived the re-
spective follow-ups. One failed
implant (mobile) at the 3-month
follow-up was excluded from the
analysis.44 The k coefficient be-
tween two authors (C-TL, C-YT) in
data extraction was 1.00.
Figure 1.
Search strategy and process.
Study Characteristics
All studies used subepithelial con-
nective tissue (CT) grafts. Imme-
heterogeneity, or insufficient data, only descriptive diate provisionalization was performed in six of 10
analysis would be performed. studies. 24,44-48 Healing abutment was placed af-
ter immediate implantation in one study. 29 An-
Statistical Analyses
other three studies used a two-stage approach.49-51
Heterogeneity among studies was assessed using
Xenografts were placed after implantation in six
heterogeneity x2 and I2 statistic. If the heterogeneity
studies,24,44,45,47,48,50 and one study used a combi-
was significant (P value of heterogeneity x2 <0.05),
nation of xenograft and allograft.46 Smokers were
a random-effects model (Dersimonian–Laird test) was
excluded in six studies24,44-46,48,51 (Table 1).
used.37 Otherwise, the fixed-effects model was ap-
plied. Meta-analysis was performed on the changes of Quality Assessment
BGL, IGL, and KG.42,43 The weighted mean difference Two RCTs scored five47 and four48 low risk of bias
of BGL (WDBGL), weighted mean difference of width items of nine assessment items, respectively (see
of KG (WDKG), weighted mean difference of papillae supplementary Appendix 4 in online Journal of Peri-
index score (WDPIS), and risk ratio of an interproximal odontology). The mean NOS score was 5.5 – 0.8
site having less than half papilla (RRHP) after IMITG (range, 5 to 7) in eight cohort studies (see supple-
between the baseline and the last appointments were mentary Appendix 5 in online Journal of Periodon-
calculated (see supplementary Appendix 2 in online tology). The k coefficient between two authors (C-TL,
Journal of Periodontology). The weighted mean dif- C-YT) in quality assessments of RCTs and cohort
ference of BGL change (WDBGC) between the IMITG studies was 1.00 and 0.94, respectively.
group and the control group was also assessed (see
BGL
supplementary Appendix 2 in online Journal of Peri-
BGL was measured in six studies (Table 2).24,44,45,47,48,50
odontology). Forest plots were generated to dem-
Four of the six studies24,44,45,48 measured BGL on the
onstrate the individual and pooled effect estimates
casts with periodontal probe, one study47 measured
and 95% confidence intervals (CIs). Publication bias
was analyzed by Egger test. All statistical analyses i STATA v.11.2, 2009, StataCorp, College Station, TX.

158
 Table 1.
Characteristics of Selected Studies

Smoking
Number Follow-Up Status
Study Number of of Period (cigarettes Level of Implant Treatment Recipient Site Bone
Author Design Patients Implants (months) daily) Implant Sites Platform Protocol Preparation Graft Membrane
J Periodontol • February 2016

Covani et al. Cohort 10 (5 males, 10 12 £10 Max/Mand Palatal bone crest Two-stage No flap No bone No membrane
200749 5 females) premolar graft
to premolar

Kan et al. 200924 Cohort 20 (6 males, 20 25.8 No smoking Max canine to N/A One-stage Bilaminar Xenograft No membrane
14 females) canine with envelope was
immediate created at the
provisional facial site
Chung et al. Cohort 10 (6 males, 10 12 No smoking Max/Mand 3 mm apical One-stage Full-thickness Xenograft No membrane
201144 4 females) premolar to the with envelope was
to premolar predetermined immediate created at the
gingival margin provisional facial site
Grunder et al. Cohort 24 Test, 12; 6 N/A Max canine to N/A Two-stage Test, partial flap; No bone No membrane
201129 control, canine control, no graft
12* flap
Tsuda et al. Cohort 10 (4 males, 10 12 No smoking Max premolar 3 mm apical One-stage Full-thickness Xenograft No membrane
201145 6 females) to premolar to the with envelope was
predetermined immediate created at the
gingival margin provisional facial site
Lee et al. 201250 Cohort 10 (2 males, 11 24 N/A Max incisors 2 to 3 mm below One-stage Full-thickness flap Xenograft If bony defect
8 females) the cemento- with >3 mm, full
enamel junction healing coverage
of the adjacent abutment with
tooth resorbable
collagen
membrane
(n = 5)

Rungcharassaeng Cohort 55 (21 males, Test, 31; Test, 10.2; No smoking Max canine to N/A One-stage Bilaminar Xenograft/ No membrane
et al. 201246 34 females) control, control, canine with envelope was allograft
24* 8.6 immediate created at the
provisional facial site
Lee, Tao, Stoupel

159
Immediate Implant Combined With Soft Tissue Graft Placement Volume 87 • Number 2

BGL on pictures of the casts, and another study50

Xenograft No membrane

No membrane

Xenograft No membrane
measured BGL on the clinical photographs. In

Membrane
regard to the reference point for the measure-
ments, one study50 used incisal tooth plane, one
study47 measured the change of crown height,
and the remaining four studies performed mea-

No bone
surements with stents. Five of six studies used
Graft
Bone

graft
immediate provisionalization, and one study50
performed coronally advanced flaps with a staged
approach. One study47 provided two datasets in

created at the

created at the
Test, partial flap;

envelope was

envelope was
Recipient Site

the meta-analysis because of separate reporting

Preparation

control, no

Full-thickness
facial site

facial site
of thin or thick biotype outcomes.
Bilaminar

The BGL did not change significantly after

flap

IMITG (WDBGL, 0.07 mm; 95% CI = -0.44 to

0.59; I2 = 92.3%) (Fig. 2). When the study
performing a staged approach was excluded,50
provisional

provisional
immediate

immediate
Treatment
Protocol

One-stage

One-stage
Two-stage

BGL still remained stable after IMITG (WDBGL,

-0.20 mm; 95% CI = -0.45 to 0.05; I2 = 60.7%).
with

with

The two RCTs directly compared the changes

of BGL in the IMITG group and the control
Level of Implant

gingival margin

group.47,48 IMITG demonstrated significantly

determined
to the pre-
Platform

less apical migration of BGL than immediate

Max premolar 3 mm apical
N/A

N/A

implantation alone (WDBGC, 0.40 mm; 95%

CI = -0.11 to 0.68).
Four24,44,45,50 of the six studies did not report
inflammatory indices. The effect of inflammatory
† One patient dropped out in the control group because of lack of compliance with the planned follow-up visits.
to premolar

to premolar

to premolar
Max premolar
Implant Sites

status on the parameters of interest is not clear.

premolar
Max/Mand

IGL
Six studies documented position of the inter-
proximal gingiva,24,44,45,47,48,50 but only two of
No smoking

No smoking
(cigarettes

the six studies47,50 reported linear change of

Smoking
Status

daily)

£10

IGL. All studies except one47 used the papillae

* The test group had IMITG, and the control group had immediate implantation alone.

index score (PIS) to evaluate change of IGL

(Table 2). Four studies 44,45,48,50 were se-
Follow-Up

lected to calculate WDPIS and RRHP during

(months)
Period

the follow-up. One study24 was excluded

24

12

12

from the analyses because of a lack of the

score-change report of mesial or distal sites.
Test, 10*;
Characteristics of Selected Studies

Number

Test, 24;
Implants

IGL after IMITG did not change significantly

control,

control,
23*†

(WDPIS, 0.31; 95% CI = -0.01 to 0.64; I2 = 0%;

10

10
of

N/A = not applicable; Max = maxilla; Mand = mandible.

RRHP, 0.58; 95% CI = 0.26 to 1.29; I2 = 0% in

the mesial site; WDPIS, 0.29; 95% CI = -0.06
25 females)

13 females)
48 (23 males,
Number of

to 0.65; I2 = 0%; RRHP, 0.52; 95% CI = 0.21 to

5 females)
Cohort 10 (5 males,

20 (7 males,
Patients

1.33; I2 = 0% in the distal site) (Figs. 3 and 4).

The heterogeneity of data was not significant.
Only one study48 demonstrated no significant
PIS differences in the mesial or distal sites be-
Design
Study
Table 1. (continued )

tween the groups up to 1 year postoperatively

RCT

RCT

(Table 2).
Two studies reported the linear change of
Migliorati et al.

IGL: 1) one50 demonstrating a slight increase

Yoshino et al.

(mesial site, 0.1 – 0.5 mm; distal site, 0.3 – 0.5 mm)
Jyothi et al.
201547

201351

201448
Author

between the initial and the 2-year follow-ups;

and 2) another47 demonstrating IGL augmenta-
tion after definitive crown placement, although

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J Periodontol • February 2016 Lee, Tao, Stoupel

Figure 2.
WDBGL or ES (effect estimate) showing difference between initial measurement and the last measurement.

there was no significant difference in IGL change be- and the outmost facial gingiva measured clinically with
tween groups with or without soft tissue grafting. a periodontal probe. Gain of 0.34 mm (12 cases, range
of 0 to 1.5 mm) and loss of 1.06 mm (12 cases, range
FGT and RD
of 0.25 to 2 mm) in RD was observed with or without CT
Three studies measured change of FGT after IMITG
grafts, respectively, at the 6-month follow-up, although
(Table 2).24,46,47 One of the three studies24 catego-
no statistical analysis was performed (Table 2).
rized gingival biotype as thin or thick based on
periodontal probe visual detection through the tis- KG
sue. Twelve of 20 cases were categorized as thin Four studies measured KG on the facial aspect at
biotype preoperatively. All 20 cases were assigned the baseline and the last follow-up appointment
thick biotype at the last follow-up. (Table 2).47,49-51 The KG increased significantly after
Another study46 measured FGT 2 mm submarginally. IMITG (WDKG, 1.27 mm; 95% CI = 0.08 to 2.46; I2 =
Increase in FGT was 1.43 – 0.59 mm (31 cases, 98.4%). When the only study47 conducting immediate
follow-up period of 10.1 months) and 0.32 – 0.36 mm provisionalization was excluded from the analysis, an
(24 cases, follow-up period of 8.6 months), respec- additional increase in the KG was observed (WDKG,
tively, with or without CT grafts. Initial gain followed by 2.27 mm; 95% CI = 1.45 to 3.09; I2 = 95.1%).
gradual decrease in gingival thickness after IMITG has One study reported no significant difference in the
been reportred as well (baseline, 1.1 – 0.6 mm; im- change of KG between the IMITG group and the control
mediately after surgery, 3.5 – 0.7 mm; 1-year follow- group at the 2-year follow-up (percentage of decrease,
up, 1.8 – 0.8 mm; 2-year follow-up, 1.5 – 0.8 mm). -10% – 6.7% versus -17.6% – 9.9%).47
Results of these studies demonstrate considerable gain
in facial thickness after IMITG within 2 years, although Publication Bias
temporal stability of this gain has to be elucidated No statistically significant publication bias of WDBGL,
further. WDPIS (mesial site or distal site), and WDKG was
Only one study measured change of RD29 defined as detected (Egger test, P = 0.68, 0.62, 0.82, and 0.75,
the horizontal distance between the implant platform respectively).

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Immediate Implant Combined With Soft Tissue Graft Placement Volume 87 • Number 2

Figure 3.
WDPIS between the initial measurement and the last measurement at the mesial site.

Figure 4.
WDPIS between the initial measurement and the last measurement at the distal site.

162
 Table 2.
Clinical Outcomes of Selected Studies

Change of Facial Gingival Change of FGT or Gingival Change of Width of Facial Mean Interproximal Bone Standardized
Study Level (mm)* Change of IGL (PIS) RD* Keratinized Tissue (mm)* Loss (mm) Radiographically Radiography

Covani et al. 200749 N/A N/A N/A 2.8 1.5 – 0.5 +

24
Kan et al. 2009 Out of 40 sites: baseline: Facial gingival biotype: N/A
J Periodontol • February 2016

0.13 – 0.61 Mesial, 0.54 – 0.42; +

score 2 = 5 sites; score baseline: thin, 12 of 20; distal, 0.47 – 0.45
3 = 35 sites; the last thick, 8 of 20; the last
follow-up: score 2 = 8 follow-up: thin, 0 of 20;
sites; score 3 = 32 sites thick, 20 of 20
Chung et al. 201144 -0.05 Out of 18 sites: baseline: N/A N/A 0.31 – 0.34 +
score 0 = 1 site; score
1 = 1 site; score 2 = 4
sites; score 3 = 12 sites;
the last follow-up: score
0 = 1 site; score 1 =1
site; score 2 = 2 sites;
score 3 =14 sites
Grunder et al. N/A NA Facial gingival RD: test, 0.34; N/A N/A N/A
201129 control, -1.063
Tsuda et al. 201145 -0.05 Out of 20 sites: baseline: N/A N/A -0.10 – 0.18 +
score 0 = 3 sites; score
1 = 2 sites; score 2 = 6
sites; score 3 = 9 sites;
the last follow-up: score
0 = 3 sites; score 1 = 1
site; score 2 = 3 sites;
score 3 = 13 sites
Lee et al. 201250 -1.7 – 0.7 Out of 22 sites: baseline: N/A 2.5 – 0.6 N/A N/A
score 1 = 4 sites; score
2 = 13 sites; score 3 = 5
sites; the last follow-up:
score 1 = 0 sites; score
2 = 14 sites; score 3 = 8
sites
Rungcharassaeng N/A N/A FGT: test, 1.43 – 0.59; N/A N/A N/A
et al. 201246 control, 0.32 – 0.36
Lee, Tao, Stoupel

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Immediate Implant Combined With Soft Tissue Graft Placement Volume 87 • Number 2

Quality of Evidence
Standardized Based on GRADE guidelines,40 the
Radiography effect of IMITG on BGL, IGL, KG, and

N/A
+/+

+/+
FGT had ‘‘low’’ evidence quality. The
effect of IMITG on gingival RD had
‘‘very low’’ evidence quality (see sup-
plementary Appendix 6 in online
Keratinized Tissue (mm)* Loss (mm) Radiographically
Change of FGT or Gingival Change of Width of Facial Mean Interproximal Bone

Test, 0.086; control, 0.155

Test, 0.01 – 0.27; control,

-0.49 – 0.96
Journal of Periodontology).

DISCUSSION
Risk of GR in the site of immediate
0.14 – 0.53

implantation, in particular in the es-

thetic zone, is a significant concern for
both a clinician and a patient. One
prospective study27 demonstrated mid-
buccal recession of 0.55 – 0.55 and
FGT: test, 0.4; control, -0.2 Test, -0.4; control, -0.7

1.13 – 0.87 mm 1 and 4 years, re-

spectively, after immediate implanta-
1.53 – 0.45

tion without soft tissue grafting. Both

N/A

mid-buccal and interproximal GR

occurred after immediate implanta-
tion, but the advanced recession
(>1 mm) was not seen frequently.3
In this review, mean BGL is stable 1
Facial gingival biotype: test:

follow-up: N/A; control:

thick, 10 of 10; the last

to 2 years after IMITG.24,44,45,47,48,50

baseline: thin, 0 of 10;

baseline: thin, 3 of 10;

thick, 7 of 10; the last

Five of six studies24,44,45,47,48 in the

analysis used immediate provision-
* Positive values denote gain in incisal buccal gingival level, in FGT/gingival RD or KG on the facial aspect.
follow-up: N/A
RD*

N/A

alization. Immediate provisionalization,

in particular the effect of cervical con-
tour and contacts with adjacent den-
tition on gingival margin position, may
bias the findings compared with
non-immediately restored implants.52
baseline: score 0 = 7 sites;

0 sites; score 1 = 4 sites;

score 3 =7 sites; the last
2 = 4 sites; score 3 = 6

1 = 3 sites; score 2 = 6

0 = 4 sites; score 1 = 7
score 1 = 3 sites; score

score 0 = 2 sites; score

score 2 = 9 sites; score

sites; the last follow-up:

sites; score 3 = 9 sites;

sites; score 2 = 2 sites;

control: baseline: score
Change of IGL (PIS)

Bone grafting in these studies may

follow-up: score 0 =
Test, -0.25 – 0.35; control, Out of 20 sites: test:

have affected not only the bone re-

modeling but also soft tissue posi-
N/A

N/A

tion, because the coronal extent of

3 = 7 sites

the graft fill was not controlled. Re-

Clinical Outcomes of Selected Studies

sults of the two included RCTs47,48

demonstrated less mid-buccal re-
cession in the IMITG group than in
Change of Facial Gingival

the non-grafted group. The significant

coronal gain of BGL in one study50
Test: thin, -0.74; thick,
-0.22; control: thin,
-1.06; thick, -0.53
Level (mm)*

might be attributed to considerable

N/A

baseline recession in all included cases

-0.7 – 0.48

(mean of 3.1 – 0.7 mm) and only

partial flap coverage of the graft.
Despite these findings, a number of
Table 2. (continued )

uncontrolled factors in these studies

make it difficult to arrive at unequivocal
Jyothi et al. 201351

N/A = not applicable.

conclusions.
Migliorati et al.

Based on the results of this re-

Yoshino et al.

view,24,44,45,47,48,50 both WDPIS and

201547

201448

RRHP indicated IGL trend toward

Study

coronal shift after IMITG but without

statistical significance. A number of

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J Periodontol • February 2016 Lee, Tao, Stoupel

studies15,33,53 reported gradual papillary enlarge- and patient-level morbidity, such as pain.61,62 In this
ment after definitive restoration alone on the im- review, two studies reported complications related to
plant. Interproximal bone level of the adjacent teeth soft tissue grafting.44,45 In one study,44 two of 10
is one of the main determinants of the papillary subepithelial CT grafts underwent necrosis, and one of
height,54,55 although platform switching44,48 or these resulted in 1-mm mid-buccal recession. In an-
bone grafting24,44,45,47,48,50 may also affect the IGL. other study,45 two of 10 subepithelial CT grafts un-
Most of the included studies used minimally invasive derwent necrosis at two sites, resulting in 1.0 and 1.5 mm
flaps for CT graft insertion. This conservative ap- mid-buccal GRs, respectively. In other words, if 10%
proach may explain the limited contribution of IMITG of patients in these studies demonstrated a compro-
to papillary height preservation. mised esthetic outcome of 1-mm recession, the
Although one included study46 demonstrated gain question arises whether the benefit may outweigh the
of 1 mm in the gingival thickness after IMITG com- risk. Larger-scale studies would be beneficial to further
pared with the non-grafted group 8 to 10 months elucidate the topic.
postoperatively, results of the long-term stability of the
augmented gingival thickness are inconclusive, with CONCLUSIONS
another study47 demonstrating a decrease in tissue Placement of an IMITG may contribute to the stability
thickness with time. It was shown that thin gingival of the gingival level and the augmentation of soft
biotype was associated with greater GR after imme- tissue contour. However, most included studies did
diate implantation than thick gingival biotype.27,47 not have a control group to demonstrate directly the
However, one included study47 found no significant benefit of IMITG compared with an immediate im-
relationship between gain in FGT and BGL. plant alone. The heterogeneity and small sample size
One included study29 reported a mean 1.4-mm of the studies may bias the results. It is premature to
difference in horizontal facial gingival RD at 6 months endorse the advantages of IMITG based on the in-
postoperatively between the IMIGT group and the conclusive available evidence.
control group. Based on the available results, IMITG
may be effective in augmenting gingival facial con- ACKNOWLEDGMENTS
tour. More controlled studies are needed to confirm The authors thank Dr. Tzu-Shan Chiu (private practice,
this assertion. Taipei, Taiwan) and Dr. Hsiang-Yun Huang (Clinical In-
Peri-implant keratinized gingiva is beneficial for local structor, School of Dentistry, National Defense Medical
health maintenance,56,57 and adequate width of the Center) for their help in searching articles and sharing
keratinized gingiva may contribute to positive esthetic valuable experience. The authors report no conflicts of
outcomes.49,58 Significant increase in the KG after interest related to this study.
IMITG is demonstrated in this review. Three included
studies49-51 used delayed implant restoration and some REFERENCES
of the pre-extraction sites exhibiting GRs. A CT graft was 1. Botticelli D, Berglundh T, Lindhe J. Hard-tissue alter-
placed over the ridge and covered with a flap, although ations following immediate implant placement in ex-
no information was provided about flap retraction, graft traction sites. J Clin Periodontol 2004;31:820-828.
exposure during healing time, or second-stage surgical 2. Sanz M, Cecchinato D, Ferrus J, Pjetursson EB, Lang
NP, Lindhe J. A prospective, randomized-controlled
technique. Partial exposure of the CT graft during sur- clinical trial to evaluate bone preservation using im-
gery is a direct technique to increase keratinized gingiva plants with different geometry placed into extraction
around teeth59 or implants.20 Another study47 demon- sockets in the maxilla. Clin Oral Implants Res 2010;21:
strated slight decrease in the KG in the test group, 13-21.
showing no benefit of the soft tissue grafting. Immediate 3. Cosyn J, Hooghe N, De Bruyn H. A systematic review
on the frequency of advanced recession following
provisionalization of the implants necessitating minimal single immediate implant treatment. J Clin Periodontol
manipulation of the soft tissue may explain this out- 2012;39:582-589.
come. Lack of control groups in most of the studies 4. van Kesteren CJ, Schoolfield J, West J, Oates T. A
precluded direct measurement of the advantage of prospective randomized clinical study of changes in
IMITG in gain of keratinized gingiva. soft tissue position following immediate and delayed
implant placement. Int J Oral Maxillofac Implants
Pink esthetic score (PES) is an evaluation system 2010;25:562-570.
commonly used to assess clinical outcomes of soft 5. Lee CT, Chiu TS, Chuang SK, Tarnow D, Stoupel J.
tissue after implant placement.60 However, only one Alterations of the bone dimension following immediate
included study47 conducted this assessment. The mean implant placement into extraction socket: Systematic
score of PES index in the IMITG group was significantly review and meta-analysis. J Clin Periodontol 2014;41:
914-926.
higher than that in the control group. 6. Allen EP, Gainza CS, Farthing GG, Newbold DA.
Soft tissue grafting carries the inherent risk of local Improved technique for localized ridge augmentation.
complications, such as bleeding, swelling, graft necrosis, A report of 21 cases. J Periodontol 1985;56:195-199.

165
Immediate Implant Combined With Soft Tissue Graft Placement Volume 87 • Number 2

7. Studer SP, Lehner C, Bucher A, Schärer P. Soft tissue graft with single immediate tooth replacement in the
correction of a single-tooth pontic space: A compara- esthetic zone: Consecutive case report. J Oral Maxillo-
tive quantitative volume assessment. J Prosthet Dent fac Surg 2009;67(11, Suppl):40-48.
2000;83:402-411. 25. Stimmelmayr M, Allen EP, Reichert TE, Iglhaut G. Use
8. Langer B, Langer L. Subepithelial connective tissue of a combination epithelized-subepithelial connective
graft technique for root coverage. J Periodontol 1985; tissue graft for closure and soft tissue augmentation of
56:715-720. an extraction site following ridge preservation or im-
9. Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plant placement: Description of a technique. Int J
plastic surgery procedures in the treatment of localized Periodontics Restorative Dent 2010;30:375-381.
facial gingival recessions. A systematic review. J Clin 26. Araújo MG, Lindhe J. Dimensional ridge alterations
Periodontol 2014;41(Suppl. 15):S44-S62. following tooth extraction. An experimental study in the
10. Edel A. Clinical evaluation of free connective tissue dog. J Clin Periodontol 2005;32:212-218.
grafts used to increase the width of keratinised gingiva. 27. Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman
1974. Periodontal Clin Investig 1998;20:12-20. G. Facial gingival tissue stability following immediate
11. Müller HP, Eger T, Schorb A. Gingival dimensions after placement and provisionalization of maxillary anterior
root coverage with free connective tissue grafts. J Clin single implants: A 2- to 8-year follow-up. Int J Oral
Periodontol 1998;25:424-430. Maxillofac Implants 2011;26:179-187.
12. Oates TW, Robinson M, Gunsolley JC. Surgical thera- 28. Bianchi AE, Sanfilippo F. Single-tooth replacement by
pies for the treatment of gingival recession. A system- immediate implant and connective tissue graft: A 1-9-
atic review. Ann Periodontol 2003;8:303-320. year clinical evaluation. Clin Oral Implants Res 2004;
13. Yan JJ, Tsai AY, Wong MY, Hou LT. Comparison of 15:269-277.
acellular dermal graft and palatal autograft in the 29. Grunder U. Crestal ridge width changes when placing
reconstruction of keratinized gingiva around dental implants at the time of tooth extraction with and without
implants: A case report. Int J Periodontics Restorative soft tissue augmentation after a healing period of 6
Dent 2006;26:287-292. months: Report of 24 consecutive cases. Int J Peri-
14. Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, odontics Restorative Dent 2011;31:9-17.
Chambrone LA, Lima LA. Root-coverage procedures 30. Botticelli D, Renzi A, Lindhe J, Berglundh T. Implants in
for the treatment of localized recession-type defects: A fresh extraction sockets: A prospective 5-year follow-
Cochrane systematic review. J Periodontol 2010;81: up clinical study. Clin Oral Implants Res 2008;19:
452-478. 1226-1232.
15. Grunder U. Stability of the mucosal topography around 31. Covani U, Chiappe G, Bosco M, Orlando B, Quaranta
single-tooth implants and adjacent teeth: 1-year re- A, Barone A. A 10-year evaluation of implants placed
sults. Int J Periodontics Restorative Dent 2000;20:11- in fresh extraction sockets: A prospective cohort study.
17. J Periodontol 2012;83:1226-1234.
16. Burkhardt R, Joss A, Lang NP. Soft tissue dehiscence 32. De Bruyn H, Raes F, Cooper LF, et al. Three-years
coverage around endosseous implants: A prospective clinical outcome of immediate provisionalization of
cohort study. Clin Oral Implants Res 2008;19:451-457. single Osseospeed() implants in extraction sockets
17. Lee CT, Hamalian T, Schulze-Späte U. Minimally in- and healed ridges. Clin Oral Implants Res 2013;24:
vasive treatment of soft tissue deficiency around an 217-223.
implant-supported restoration in the esthetic zone: 33. Sanz M, Cecchinato D, Ferrus J, et al. Implants placed
Modified VISTA technique case report. J Oral Implantol in fresh extraction sockets in the maxilla: Clinical and
2015;41:71-76. radiographic outcomes from a 3-year follow-up exam-
18. Evian CI, Cutler S. Autogenous gingival grafts as epithelial ination. Clin Oral Implants Res 2014;25:321-327.
barriers for immediate implants: Case reports. J Peri- 34. Needleman IG. A guide to systematic reviews. J Clin
odontol 1994;65:201-210. Periodontol 2002;29(Suppl. 3):6-9, discussion 37-38.
19. Landsberg CJ, Bichacho N. A modified surgical/prosthetic 35. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA
approach for optimal single implant supported crown. Part statement for reporting systematic reviews and meta-
I — The socket seal surgery. Pract Periodontics Aesthet analyses of studies that evaluate health care interven-
Dent 1994;6:11-17, quiz 19. tions: Explanation and elaboration. J Clin Epidemiol
20. Edel A. The use of a connective tissue graft for closure 2009;62:e1-e34.
over an immediate implant covered with occlusive 36. Higgins JP, Green S. Chapter 5: Defining the review
membrane. Clin Oral Implants Res 1995;6:60-65. question and developing criteria for including studies.
21. Rosenquist B. A comparison of various methods of soft Cochrane Handbook for Systematic Reviews of Inter-
tissue management following the immediate place- ventions: Cochrane Book Series. Chichester, UK: Wiley;
ment of implants into extraction sockets. Int J Oral 2011.
Maxillofac Implants 1997;12:43-51. 37. Higgins JP, Altman DG, Gøtzsche PC, et al; Cochrane
22. Stimmelmayr M, Stangl M, Edelhoff D, Beuer F. Clinical Bias Methods Group; Cochrane Statistical Methods
prospective study of a modified technique to extend the Group. The Cochrane Collaboration’s tool for assessing
keratinized gingiva around implants in combination with risk of bias in randomised trials. BMJ 2011;343:d5928.
ridge augmentation: One-year results. Int J Oral Max- 38. Dekkers OM, Egger M, Altman DG, Vandenbroucke JP.
illofac Implants 2011;26:1094-1101. Distinguishing case series from cohort studies. Ann
23. Matthews DP. The pediculated connective tissue graft: Intern Med 2012;156:37-40.
A novel approach for the ‘‘blown-out’’ site in the 39. Wells G, Shea B, O’Connell D, et al. The Newcastle-
esthetic zone. Compend Contin Educ Dent 2008;29: Ottawa Scale (NOS) for assessing the quality of non-
350-352, 354, 356-357. randomised studies in meta-analyses. 2001. Available
24. Kan JY, Rungcharassaeng K, Morimoto T, Lozada J. at http://www.ohri.ca/programs/clinical_epidemiology/
Facial gingival tissue stability after connective tissue oxford.asp. Accessed March 12, 2015.

166
J Periodontol • February 2016 Lee, Tao, Stoupel

40. Guyatt GH, Oxman AD, Vist GE, et al; GRADE Working 52. De Rouck T, Collys K, Wyn I, Cosyn J. Instant
Group. GRADE: An emerging consensus on rating provisionalization of immediate single-tooth implants
quality of evidence and strength of recommendations. is essential to optimize esthetic treatment outcome.
BMJ 2008;336:924-926. Clin Oral Implants Res 2009;20:566-570.
41. Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, 53. Jemt T. Regeneration of gingival papillae after single-
Knottnerus A. GRADE guidelines: A new series of implant treatment. Int J Periodontics Restorative Dent
articles in the Journal of Clinical Epidemiology. J Clin 1997;17:326-333.
Epidemiol 2011;64:380-382. 54. Tarnow DP, Magner AW, Fletcher P. The effect of the
42. Higgins JP, Green S. Chapter 16.3.2: Imputing stan- distance from the contact point to the crest of bone on
dard deviations for changes from baseline. Cochrane the presence or absence of the interproximal dental
Handbook for Systematic Reviews of Interventions: papilla. J Periodontol 1992;63:995-996.
Cochrane Book Series. Chichester, UK; 2011. 55. Tarnow D, Elian N, Fletcher P, et al. Vertical distance
43. Follmann D, Elliott P, Suh I, Cutler J. Variance impu- from the crest of bone to the height of the interproximal
tation for overviews of clinical trials with continuous papilla between adjacent implants. J Periodontol 2003;
response. J Clin Epidemiol 1992;45:769-773. 74:1785-1788.
44. Chung S, Rungcharassaeng K, Kan JY, Roe P, Lozada 56. Schrott AR, Jimenez M, Hwang JW, Fiorellini J, Weber
JL. Immediate single tooth replacement with subepi- HP. Five-year evaluation of the influence of keratinized
thelial connective tissue graft using platform switching mucosa on peri-implant soft-tissue health and stability
implants: A case series. J Oral Implantol 2011;37:559- around implants supporting full-arch mandibular fixed
569. prostheses. Clin Oral Implants Res 2009;20:1170-
45. Tsuda H, Rungcharassaeng K, Kan JY, Roe P, Lozada 1177.
JL, Zimmerman G. Peri-implant tissue response fol- 57. Lin GH, Chan HL, Wang HL. The significance of kerati-
lowing connective tissue and bone grafting in conjunc- nized mucosa on implant health: A systematic review. J
tion with immediate single-tooth replacement in the Periodontol 2013;84:1755-1767.
esthetic zone: A case series. Int J Oral Maxillofac 58. Belser U, Buser D, Higginbottom F. Consensus state-
Implants 2011;26:427-436. ments and recommended clinical procedures regard-
46. Rungcharassaeng K, Kan JY, Yoshino S, Morimoto T, ing esthetics in implant dentistry. Int J Oral Maxillofac
Zimmerman G. Immediate implant placement and Implants 2004;19(Suppl.):73-74.
provisionalization with and without a connective tissue 59. Han JS, John V, Blanchard SB, Kowolik MJ, Eckert GJ.
graft: An analysis of facial gingival tissue thickness. Int Changes in gingival dimensions following connective
J Periodontics Restorative Dent 2012;32:657-663. tissue grafts for root coverage: Comparison of two
47. Migliorati M, Amorfini L, Signori A, Biavati AS, procedures. J Periodontol 2008;79:1346-1354.
Benedicenti S. Clinical and aesthetic outcome with 60. Belser UC, Grütter L, Vailati F, Bornstein MM, Weber
post-extractive implants with or without soft tissue aug- HP, Buser D. Outcome evaluation of early placed
mentation: A 2-year randomized clinical trial. Clin Im- maxillary anterior single-tooth implants using objective
plant Dent Relat Res 2015;17:983-995. esthetic criteria: a cross-sectional, retrospective study
48. Yoshino S, Kan JY, Rungcharassaeng K, Roe P, Lozada in 45 patients with a 2- to 4-year follow-up using pink
JL. Effects of connective tissue grafting on the facial and white esthetic scores. J Periodontol 2009;80:140-
gingival level following single immediate implant 151.
placement and provisionalization in the esthetic zone: 61. Tal H. Autogenous masticatory mucosal grafts in
A 1-year randomized controlled prospective study. Int extraction socket seal procedures: A comparison be-
J Oral Maxillofac Implants 2014;29:432-440. tween sockets grafted with demineralized freeze-dried
49. Covani U, Marconcini S, Galassini G, Cornelini R, bone and deproteinized bovine bone mineral. Clin Oral
Santini S, Barone A. Connective tissue graft used as Implants Res 1999;10:289-296.
a biologic barrier to cover an immediate implant. J 62. Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Post-
Periodontol 2007;78:1644-1649. operative complications following gingival augmenta-
50. Lee YM, Kim DY, Kim JY, et al. Peri-implant soft tissue tion procedures. J Periodontol 2006;77:2070-2079.
level secondary to a connective tissue graft in conjunc-
tion with immediate implant placement: A 2-year Correspondence: Dr. Janet Stoupel, Division of Periodon-
follow-up report of 11 consecutive cases. Int J Peri- tics, Section of Oral and Diagnostic Sciences, College of
odontics Restorative Dent 2012;32:213-222. Dental Medicine, Columbia University, 630 W. 168th St.,
51. Jyothi SG, Triveni MG, Mehta DS, Nandakumar K. New York, NY, 10032. Fax: 718/896-3045; e-mail: js108@
Evaluation of single-tooth replacement by an immedi- cumc.columbia.edu.
ate implant covered with connective tissue graft as
a biologic barrier. J Indian Soc Periodontol 2013;17: Submitted June 24, 2015; accepted for publication August
354-360. 16, 2015.

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