pdf biotipo implant review 2011

Soft Tissue Biotype AffectsImplant Success

Angie Lee, DMD, MS,* Jia-Hui Fu, BDS,† and Hom-Lay Wang, DDS, MSD, PhD‡

The extensive scientific literaturepublished in the field of implan-tology offers a plethora of criteria

to define implant success.1–3 Examplesof traditional clinical parameters used tomeasure success include marginal boneloss, sulcus depth, and mobility. Re-cently, the agreement among theInternational Congress of Oral Implan-tologists is that a successful implantshould fulfill both functional and estheticcriteria.4 Appraisal of esthetics is an im-portant aspect that entails personal eval-uation of the conformity of the orofacialcomplex to the community standard ofbeauty, with achievement of an im-proved smile and self-image.5 A suc-cessful esthetic outcome ultimately liesin the perception of the patient. How-ever, for the clinician, assessment of es-thetic outcomes is performed throughexamination of clinical parameters, suchas level of soft tissue margin, interprox-imal papillae, and color blend of theprosthesis with the natural dentition.6,7

Multiple biological and biome-chanical factors have been reported toadversely affect implant success, forinstance the use of tobacco and the pres-

ence of occlusal overload.8–13 More re-cently, tissue thickness has also beenreported to be an important factor thatinfluences implant success.6,14,15

As far back as the late 1960s, stud-ies already reported a positive surgicalbenefit with thicker soft and hard tis-sues.16,17 Nonetheless, it was only laterthat the term “periodontal biotype” wasfirst coined by Seibert and Lindhe.18 Innatural teeth, these authors observed thata thick-flat periodontal biotype was as-sociated with quadratic teeth and widezones of keratinized gingiva. On theother hand, a thin-scalloped periodontalbiotype was associated with slenderteeth, which presented with narrow zonesof keratinized gingiva. These previous ob-servations made in the late 1980s werehighly subjective leading other authors toquantify gingival thickness in relation toperiodontal inflammation; these authorsdefined thin gingival tissues as �1.5 mmand thick gingival tissues as �2.0 mm.19

Looking into the evidence available, onecan gather that thick biotypes have a flatarchitecture and, when subjected to me-chanical and/or surgical trauma, are inher-

ently more resistant to recession leading toformation of periodontal pockets and infr-abony defects. In contrast, thin biotypeshave a scalloped appearance and respondreadily to mechanical insults with gingivalrecession.20–25 Furthermore, a systematicreview conducted by Hwang and Wang26

well demonstrated the importance of aminimal flap thickness to achieve com-plete root coverage around teeth.

Extrapolating the observations ofsoft tissue behavior around natural teeth,the periimplant soft tissue can also becategorized into thin and thick biotypes.However, definitions of this classifica-tion varied among different studies. Ac-cording to Kan et al21, a thin biotype isone where the outline of the periodontalprobe can be seen through the marginaltissue when probing, whereas a thickbiotype is one where the probe is cam-ouflaged by the marginal tissue. Similarto gingival tissue, thin periimplant softtissue is more susceptible to soft tissuerecession compared with thick periim-plant soft tissue.14 This feature can beattributed to thinner tissues being morefriable, less vascularized, and accompa-

*Adjunct Clinical Assistant Professor and Research Fellow,Department of Periodontics and Oral Medicine, School ofDentistry, University of Michigan, Ann Arbor, MI.†Resident, Department of Periodontics and Oral Medicine,School of Dentistry, University of Michigan, Ann Arbor, MI.‡Professor and Director of Graduate Periodontics, Departmentof Periodontics and Oral Medicine, School of Dentistry,University of Michigan, Ann Arbor, MI.Research Advisor, Eng. A.B. Research Chair for GrowthFactors and Bone Regeneration, King Saud University Riyadh,Saudi Arabia.

Reprint requests and correspondence to: Hom-LayWang, DDS, MSD, PhD, Department of Periodonticsand Oral Medicine, University of Michigan School ofDentistry, 1011 North University Avenue, Ann Arbor,MI 48109-1078, Phone: 734763.3383, Fax:734936.0374, E-mail: [email protected]

ISSN 1056-6163/11/02003-038Implant DentistryVolume 20 • Number 3Copyright © 2011 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3182181d3d

The influence of tissue biotype innatural dentition is already well dem-onstrated in the literature, with nu-merous articles showing that thickertissue is a preferred biotype for opti-mal surgical and prosthetic outcomes.In this same line of thought, currentstudies are directed to explorewhether mucosal thickness wouldhave similar implications around den-tal implants. The purpose of this re-view was to investigate the effects ofsoft tissue biotype in relation to suc-cess of implant therapy. The influence

of tissue biotype was divided into 3main categories: its relationship withperiimplant mucosa and the underly-ing bone, immediate implant place-ment, and restorative outcomes. Softtissue biotype is an important param-eter to consider in achieving estheticimplant restoration, improving imme-diate implant success, and preventingfuture mucosal recession. (ImplantDent 2011;20:e38–e47)Key Words: tissue biotype, tissuethickness, dental implant, mucosalthickness, soft tissue, implant success

e38 SOFT TISSUE BIOTYPE AFFECTS IMPLANT SUCCESS • LEE ET AL

nied with thinner underlying bone.20 Inimplantology, the importance of a thickbiotype is further reinforced because ofthe lack of a periodontal ligament thatprovides additional blood supply duringwound healing. Therefore, it appearsreasonable that thick tissue would be adesirable feature around dental implantsboth for esthetic and functional benefits.

At present, the role of tissue bio-type in relation to parameters of im-plant success remains to be elucidated.The aim of the present review articlewas to clarify the role of periimplanttissue biotype in various implant suc-cess criteria. The effect of tissue bio-type in implant therapy was dividedinto 3 main categories: its relationshipwith periimplant mucosa and the un-derlying bone, immediate implantplacement, and restorative outcomes.

RELATIONSHIP OF TISSUEBIOTYPE WITH PERIIMPLANTMUCOSA AND THEUNDERLYING BONE

In natural dentition, biologic width,or more properly named biologic height,refers to the dentogingival junction in-cluding epithelial attachment (0.97mm), supracrestal connective tissue(1.07 mm) and, arguably, gingivalsulcus (0.69 mm).27,28 The results ofstudies conducted on cadavers showgreat individual variations in bio-logic width, especially in regard to epi-thelial attachment (1.0–9.0 mm)1.27,29

To explain this wide range of measure-ments, Muller et al30 proposed that athin periodontal biotype is associatedwith a shallower biologic widthcompared with a thick biotype. As aconsequence, a thin biotype is moresusceptible to biologic width inva-sion resulting in marginal tissue re-cession and alveolar bone loss.31

The equivalent term for biologicwidth around dental implants is periim-plant mucosa.21,32 Fundamental differ-ences exist between periimplant mucosaand its counterpart in natural teeth. Forinstance, the attachment apparatus is lo-cated subcrestal around implants but su-pracrestal around teeth. Moreover, asdemonstrated in animal studies, the av-erage periimplant mucosal dimensionwas 3 mm, which was 1 mm more thanthat of natural teeth.33–35

Periimplant mucosal dimensionsvaried according to soft tissue biotype.Kan et al evaluated dimensions of theperiimplant mucosa by bone soundingaround restored implants in humans, andreported consistently greater values inthick biotype compared with thin bio-type, although no significant differenceswere noted at the facial and distal areasof the implant. A periimplant mucosaldimension at the facial aspect of �3 mmwas associated with a thin biotype, la-bioversion of the implant and/or over-contoured facial emergence of thecrown. Conversely, thick biotypes wereassociated with a periimplant mucosaldimension of �4 mm at the facial as-pect. As a consequence, implants maybe prone to papilla loss when the dis-tance from the tip of the papilla to theunderlying bone of the adjacent naturaltooth is larger than 4 mm in a thinbiotype. In comparison, thick biotypeexperienced less papilla loss even at adistance of 4.5 mm from the papilla tipto the underlying bone crest.21 To main-tain the integrity of this papilla aftertooth extraction, clinicians should con-sider to restore the papilla before tissuecollapse.36,37 One advantageous featureis that papilla fill increased over time,with 86% of the sites demonstrating�50% papilla fill at 1-year follow-up.38

In contrast, a histological study con-ducted in dogs reported similar meanepithelial and connective tissue attach-ment in thin and thick tissue biotypes.34

Because definitions of thin and thicktissues were not provided in the latterstudy, comparison with other studieswas not possible. Furthermore, histolog-ical measurements of the attachment inanimals may yield different values frombone sounding techniques performed inhumans. In the study by Abrahamsson etal, implants were not restored, andtherefore, results obtained can only beinterpreted as the periimplant mucosabefore occlusal loading.

When evaluating periimplant tis-sue dimensions around immediateimplants, dimensions on the buccalaspect were significantly higher inimplants placed after a conventionalflap surgery compared with a flap-less surgical technique (3.69 mm vs

3.02 mm, respectively). This differ-ence was particularly observed inareas with a thin biotype, which sug-gests that flapless implant placementcan help with the reestablishment ofa smaller periimplant mucosa.39

A minimum dimension of periim-plant mucosa is necessary to maintainhealth. Similar to natural teeth, inva-sion of the periimplant mucosa causesperiimplant tissue inflammation andcrestal bone loss.34,40–42 As a result ofthis impingement and to reestablishthe mucosal dimension, angular defectwas characteristic of a thin mucosa,whereas thicker tissues demonstratedhorizontal bone loss.34,41

The interpretation of the resultsfrom multiple studies attribute earlycrestal bone loss to the location of themicrogap at the implant-abutment in-terface, which contributes to increasedmicrobial invasion, inflammatory cellinfiltrate, and mechanical stress to thecrestal bone.43–46 Although still debat-able, some authors advocate displace-ment of the implant-abutment interfaceaway from crestal bone by means ofplatform switching or supracrestal im-plant placement to prevent early boneloss.47 Two reports showed the correla-tion between tissue biotype and crestalbone loss in nonsubmerged implants.48,49

When implants were placed 2 mm su-pracrestally, subjects with a thin mucosaexhibited significantly greater mean cr-estal bone loss than subjects with a me-dium (ie, tissue thickness of 2.1–3.0mm) and thick (ie, tissue thickness of�3.1 mm) biotypes (P � 0.05). In thecontrol group where implants wereplaced at the bone level, tissue biotypedid not affect mean crestal bone loss.The authors did not recommend supra-crestal implant placement in sites withthin mucosa due to increased crestalbone loss compared with a thicker bio-type. Nonetheless, further examinationis warranted because this crestal boneloss was comparable with the controlgroup where implants were placed at thebone level. Moreover, in patients withthin biotype, implants with platformswitching failed to maintain crestal bonelevel, exhibiting results similar to tradi-tional implant-abutment connection.50

IMPLANT DENTISTRY / VOLUME 20, NUMBER 3 2011 e39

These results corroborated with previ-ous studies that reported increased softand hard tissue resorption to reestablisha healthy periimplant mucosal dimen-sion, especially in a thin biotype.34

Interestingly, periimplant tissuethickness is a dynamic entity reflected inthat following crown placement, the fa-cial mucosa of the implant increased inthickness even though a slight remissionwas observed at 1-year examination.38,51

In addition, soft tissue recession of 0.6mm was noted on the labial surfacealong with this remission, which may beattributed to the establishment of an ad-equate periimplant mucosal dimen-sion.52 Another important finding is thatmucosal thickness was related to theheight of the free marginal tissue in a1:1.5 ratio.38

The literature reviewed in this sec-tion provided insight in regard to therelation of periimplant mucosa and cr-estal bone loss with tissue thicknessmeasured before implant placement48–50

and after implant restoration21 (Table 1,Fig. 1). Periimplant mucosa typicallymeasures �3 mm in a thin tissue bio-type compared with more than 4 mm in

a thick tissue biotype. Because of theincreased susceptibility to mucosal re-cession and crestal bone loss in a thinbiotype, platform switching failed tomaintain soft and hard tissue levels. Fu-ture studies on a large patient populationwill be needed to explore the effect ofplatform switching on a thick biotype.

ROLE OF TISSUE BIOTYPEIN IMMEDIATEIMPLANT PLACEMENT

Immediate implant placement re-fers to implants placed at the time oftooth extraction. Albeit its demonstratedsuccess rate53,54 and its key advantage ofa shortened treatment time, immediateimplant placement is a technique-sensitive procedure that requires de-tailed evaluation of hard and soft tissuecomponents. In the past, immediateimplant placement was thought to min-imize physiologic bone loss that accom-panied remodeling of the extractionsocket.55 It is now known that the pro-cess of bone remodeling is an unavoid-able phenomenon56,57 and, therefore,understanding bone and soft tissue re-modeling helps to achieve more predict-

able esthetics and treatment success inimmediate implant placement.

The critical gap distance, deter-mined to be 1 to 2 mm, refers to theresidual defect between the implant andbone, and dictates the necessity ofplacing a bone graft and/or barrier mem-brane.53 Furthermore, a minimum resid-ual buccal bone thickness of 1 to 2 mmis necessary for maintenance of the bonelevel, a threshold below which hard tis-sue augmentation is recommended.54,58

Likewise, soft tissue thickness is also acritical parameter to consider and caninfluence the level of marginal tissueand presence of papilla in immediateimplant placement.

A total of 5 studies evaluated tissuebiotype around immediately placed im-plants, of which 3 were prospectivestudies (Table 2). In these studies, pa-tients with thin biotype showed in-creased mucosal recession in immediateimplant placement compared with thosewith thick biotype who showed less re-cession.59,60 In a retrospective study, Ev-ans and Chen14 reported 0.9 � 0.78 mmof mucosal tissue recession after 18.9months of function with no significantdifferences between the 2 investigated

Table 1. Studies That Correlated Tissue Biotype With Periimplant Mucosa and the Underlying Bone

Study Study Design N SiteDefinition of

BiotypeTime of

MeasurementImplantSystem

ObservationPeriod

No. ofStages

Types ofProsthesis

Abrahamssonet al34

Animal 5 Beagle dogs Mandibularpremolars

Undefined Abutment Brånemark vsAstra Techvs Bonefit

6 mo 1 and 2 Abutmentconnectionandextensioncaps

Prospective 30 Implants

Berglundh andLindhe41

Animal 5 Beagle dogs Mandibularpremolars

Thin: 2.4 mm Abutment Brånemark 6 mo 2 AbutmentconnectionProspective 30 Implants Thick: 3.3 mm

Kan et al21 Retrospective 45 Patients45 Implants

Maxillaryanteriors

Thin: probe seenthrough tissue

After prosthesis Unknown 1 yr 2 Single crowns

Thick: probe notseen throughtissue

Cardaropoliet al38

Prospective 11 Patients Maxillaryanteriors

Ultrasonic Abutmentconnection

Brånemark 1 yr 2 Single crowns11 Implants

Linkeviciuset al48

Prospective 26 Patients64 Implants

Unknown Thin: �2 mmMedium: 2.1–3

mmThick: �3.1 mm

Implantplacement

BioHorizons 1 yr 1 Single crownsand fixedpartialdenture

Linkeviciuset al49


Unknown Thin: �2 mmThick: �2.5 mm

Implantplacement

BioHorizons 1 yr 1 Single crownsand fixedpartialdenture

Linkeviciuset al50

Prospective 4 Patients Unknown Thin: �2 mm Implantplacement

3i BioHorizons 1 yr 1 Splinted crownsand fixedpartialdenture

12 Implants

Blanco et al39 Animal 5 Beagle dogs Mandibularpremolars

Undefined Unknown Straumann 3 mo 1 AbutmentconnectionProspective 20 Implants


implant systems (Straumann vs 3i). Theauthors found that areas with a thin tis-sue biotype featured increased tissue re-cession compared with a thick tissuebiotype (1.0 � 0.9 mm vs 0.7 � 0.57mm, respectively), although the resultsdid not reach statistical significance.

However, it is important to notethat a previous study published byChen et al61 did not find any rela-

tionship between tissue biotype andrecession in immediate implantplacement. Furthermore, a recentstudy examined soft tissue changesin immediate implants comparedwith delayed implants. The authorsreported favorable clinical outcomesin both groups with no significanteffect of tissue biotype on thechanges in soft tissue position.62

The conflicting data of the above-mentioned reports regarding tissuebiotype on soft tissue recession in im-mediate implants may be attributed to asample population with a particularlysmall number of sites with recession ob-served both in the study by Chen et al61

and van Kesteren et al.62 Although thereare studies that show contradictive re-sults, the overall conclusion would leadus to believe that soft tissue biotypeplays an influential role in immediateimplant placement especially in sitesthat show specific predisposition to softtissue recession. For example, when theimplant was placed facially, 85.7% (6/7)of thin biotypes had �1 mm of reces-sion compared with 66.7% (2/3) in thickbiotypes.14 Moreover, in the study byvan Kesteren et al, the lack of a defini-tion for tissue biotype and placement ofbone grafts in immediate implant sitesmake the comparison with other studiesmore difficult.

After the analysis of how a thinbiotype poses a risk of increased muco-sal recession, there is also evidence tosupport that a thin biotype is associatedwith increased susceptibility to loss ofpapilla in immediate implants. In a pro-spective study, Romeo et al63 placed 48nonsubmerged immediate implants con-nected with a transmucosal healingscrew. A dichotomous scale was used toidentify the presence or absence of pa-pilla. The results show that thick tissuebiotype was significantly associatedwith the presence of papilla when the

Fig. 1. Characteristics of thin and thick tissue biotypes.

Table 2. Studies That Examined the Role of Tissue Biotype in Immediate Implant Placement

Study Study Design N SiteDefinition of

BiotypeTime of

MeasurementImplantSystem

ObservationPeriod

No. ofStages

Types ofProsthesis

Chen et al61 Prospective 30 Patients30 Implants

Maxillary anteriorand premolars

Undefined At second stagesurgery

Straumann 3–4 yr 2 Single crown

Evans andChen14

Retrospective 42 Patients42 Implants

Maxillary andmandibularanterior andpremolars

Thin: probe seenthrough labialtissue

After prosthesis 3i, Straumann 18.9 mo(6–50mo)

Unknown Single crown

Thick: probe notseen through

Romeoet al63


Maxillary andmandibularanterior andpremolar

Thin: Probe seenthrough labialtissue

After prosthesis Straumann 1 yr 1 Single crown

Thick: probe notseen through

Chen et al59 Retrospective 85 Patients85 Implants

Maxillary incisors Thin �1 mm Surgery Straumann 1 yr 1 Single crownThick �1 mm

van Kesterenet al62


Maxillary anteriors;maxillary andmandibularpremolars

Undefined Unknown Straumann 6 mo 1 Unknown


contact point was 3 to 7 mm from thebone crest (P � 0.05), a finding substan-tiated by previous reports in the litera-ture.64,65 The presence of papilla wasobserved in 84% of subjects with thickbiotype compared with 42.8% of sub-jects with thin biotypes.63

Thick biotype is associated with arather flat architecture suggesting thepresence of a shorter papilla heightcompared with longer papilla in thethin biotype. In areas of high estheticdemands and for subjects with thinbiotype, soft tissue enhancement isbeneficial to maintain and reconstructadequate papilla height if immediateimplant placement is considered.66 Al-ternatively, loss of papilla can be cam-ouflaged by modifying the shape andcontour of the prosthesis. This can beachieved by positioning the contactpoint in a more apical position, and byfavoring rectangular over triangularcrown shapes.6

RELATIONSHIP OFTISSUE BIOTYPE WITHRESTORATIVE OUTCOMES

Esthetic outcomes have gained in-creasing importance and are now in-corporated as a parameter of implantsuccess.67 The grayish shadow shownthrough the tissue is a major disadvan-tage of titanium implants with metalabutments and a source of undesirableesthetics. In an in vitro study wheretissue color changes were measuredutilizing a spectrophotometer, the au-thors found that zirconia did notinduce color changes visible to thehuman eye in mucosal thickness of 2to 3 mm, whereas titanium producedthe most color changes for the samemucosal characteristics. Nonetheless,both materials induced a “noticeable”color difference in a mucosal thick-ness of 1.5 mm.15

In contrast, a human study re-ported that periimplant soft tissuethickness was not correlated with thedegree of color changes induced bydifferent abutment materials. How-ever, while all 3 materials inducedcolor changes in periimplant soft tis-sues, titanium abutments producedsignificantly greater color changes onsoft tissues compared with gold andzirconium oxide abutments.68

The conflicting conclusions ob-tained by Jung et al and Bressan et alin regard to the effect of abutmentmaterials on soft tissue thickness maybe attributed to the differences be-tween in vivo and in vitro studies. Inthe study by Bressan et al, none of thesubjects displayed a tissue thickness�3 mm. Because soft tissue thicknessin vivo does not typically measureabove 3 mm, zirconium abutments arepreferred for both biotypes in the es-thetic zone to minimize color changesin the mucosa and maximize estheticresults (Fig. 1, Table 3).

CURRENT LIMITATIONS ANDFUTURE DIRECTIONS

Drawbacks of existing studies in-clude the limited sample size and het-erogeneity in study methodology. Theheterogeneity in methodology of thestudies requires exerting caution wheninterpreting the results. The lack of aconsensus among the various studiesin the definition of tissue biotype con-stitutes an important matter. Severalauthors considered the tissue thinwhen the transparency of the peri-odontal probe can be seen through thesulcus, whereas they were consideredthick when the probe cannot beseen.14,21 However, other authors de-fined a thin biotype as a tissue thick-ness measurement of �1 to 2 mm, andthat of a thick biotype as �1 to 2

mm.48,60 In the study by Chen et al, theauthors measured tissue biotype by de-termining the width of keratinized tis-sue; for example, a width of keratinizedtissue of �5 mm is categorized as a thinbiotype, whereas a width of keratinizedtissue of �5 mm is defined as a thickbiotype, as referenced by Muller etal.30,59 In addition, the area where tissuethickness was measured also variedfrom one study to the other.

The method used to assess tissuethickness differed greatly among stud-ies. The report by Jung et al measuredtissue thickness using a caliper,15

whereas Linkevicius et al measured tis-sue thickness using a periodontal probewith direct visual assessment before el-evating the buccal flap.48 The use ofultrasonics to measure tissue thickness isalso a valid and reliable method.25,69

Nonetheless, the additional cost andtechnical difficulty of working with thetransducer have limited the practicalityof this device to mainly research use.70

Another frequently used method is eval-uating the transparency of the periodon-tal probe through the labial sulcus. Anintraexaminer reproducibility of 85%has been reported, which confirms theclinical use of this method (k � 0.70;P � 0.002).71 The authors of the latterstudy believed that an accurate and ob-jective assessment of tissue biotypeshould be based on direct soft tissuethickness measurement using a peri-odontal probe or an endodontic file.Nonetheless, it is important to highlightlimitations associated with this tech-nique such as the necessity of local an-esthesia, and the variations associatedwith probe angulation and pressure.Furthermore, the accuracy of the NorthCarolina periodontal probe is limited be-cause its resolution is 1 mm.72 Despitethese drawbacks, these techniques allow

Table 3. Studies That Correlated Tissue Biotype With Restorative Outcomes

StudyStudyDesign N Site

Definition ofBiotype

Time ofMeasurement

ImplantSystem

ObservationPeriod

No. ofStages

Types ofProsthesis

Jung et al15 In vitro 10 Pig maxillae Palatalmucosa

Thickness of1.5, 2.0, and3.0 created

NA NA NA NA NA

Bressanet al68

Prospective 20 Patients Maxillaryanteriors

Thin: �2 mm On cast Astra Tech NA 2 Single crownThick: �2 mm

NA, not applicable.


clinicians to have an acceptable estima-tion of the thickness of tissues.

In a recent study applying clusteranalysis, 100 patients were dividedinto 3 categories: thin-scalloped,thick-flat, and thick-scalloped. Bothexperienced and inexperienced clini-cians were asked to visually assesstissue biotypes. Experienced clinicianswere able to accurately recognize thethick-flat biotype in more than 70% ofthe cases but were unable to identifyalmost 50% of the thin-scallopedcases. These cases that were over-looked are precisely of increased sus-ceptibility for an esthetic compromise.Clearly, this emphasizes the limita-tions of visual inspection alone andcalls for the need of additional infor-mation before assessment such as theactual thickness of the tissues.49

Historically, 2 different biotypeswere identified, the thin and the thick.Discrimination between thin and thickbiotype is somewhat difficult becausemost patients do not fall into either ex-tremes. In fact, a combination of bothbiotypes may be found frequentlywithin the same patient. It was not untilrecently that some authors reported amedium biotype, with characteristicsbetween thin and thick biotypes.49,71 Infact, �80% of the sites cannot be clas-sified as neither thin nor thick accordingto the above-mentioned historical defi-nition, evidencing the deficiency of theclassification.69 Even though no signifi-cant differences were found betweenmedium and thick biotypes in the studyby Linkevicius et al,49 crestal bone losswas still decreasing as tissue thicknessincreases.

Upon this lack of agreement, aconsensus should be established to de-fine thin, medium and thick biotypes.Future studies should be directed toaddress the primary question of a crit-ical tissue thickness around implantsthat promotes better surgical and pros-thetic outcomes.

CONCLUSION

Periimplant tissue biotype is an in-trinsic parameter that affects both theesthetic and functional aspects of im-plant rehabilitation by influencing theremodeling of hard and soft tissues. Be-cause thick biotype is a desirable fea-

ture, conversion of the patient’s mucosalphenotype both quantitatively and qual-itatively through soft tissue grafting pro-vides more predictable surgical andprosthetic outcomes. Based on the clin-ical significance of periimplant tissuethickness, measurement of this parame-ter should be incorporated in the implan-tologist’s routine evaluation to developa more comprehensive treatment plan.Various tissue biotypes have differentphysiological and pathological behav-iors; therefore, treatment approachshould be tailored to each biotype toenhance predictability of treatmentoutcomes.

The assessment of soft tissue bio-type is critical in clinical practice be-cause of its effects on implant success,but yet, a reproducible and accuratemethod of measurement is still notagreed upon. A consensus should bereached in regard to biotype classifi-cation and the use of a method that canserve as the “gold standard” to evalu-ate tissue thickness. As a consequence,clinicians can communicate more effi-ciently and compare results from dif-ferent studies more precisely.

Disclosure

The authors do not have any fi-nancial interests, either directly or in-directly, in the products or informationlisted in the article.

ACKNOWLEDGMENTS

This article was partially sup-ported by the University of MichiganPeriodontal Graduate Student Re-search Funds.

REFERENCES

1. Albrektsson T, Zarb G, WorthingtonP, et al. The long-term efficacy of currentlyused dental implants: A review and pro-posed criteria of success. Int J Oral Maxil-lofac Implants. 1986;1:11-25.

2. Smith DE, Zarb GA. Criteria for suc-cess of osseointegrated endosseous im-plants. J Prosthet Dent. 1989;62:567-572.

3. Proskin HM, Jeffcoat RL, Catlin A, etal. A meta-analytic approach to determinethe state of the science on implant den-tistry. Int J Oral Maxillofac Implants.2007;22 suppl:11-18.

4. Misch CE, Perel ML, Wang HL, et al.Implant success, survival, and failure: TheInternational Congress of Oral Implantolo-

gists (ICOI) Pisa Consensus Conference.Implant Dent. 2008;17:5-15.

5. Eber RM, Bunyaratavej P, WangH-L. Periodontal treatment planning for en-hanced aesthetic outcomes. In: McNa-mara JA, Kelly KA, eds. Frontiers of Dentaland Facial Esthetics. Ann Arbor, MI: Centerfor Human Growth and Development andthe Department of Orthodontics and Pedi-atric Dentistry; 2001:123-144.

6. Bashutski JD, Wang HL. Commonimplant esthetic complications. ImplantDent. 2007;16:340-348.

7. Kazor CE, Al-Shammari K, SarmentDP, et al. Implant plastic surgery: A reviewand rationale. J Oral Implantol. 2004;30:240-254.

8. Steigenga JT, Al-Shammari KF,Nociti FH, et al. Dental implant design andits relationship to long-term implant suc-cess. Implant Dent. 2003;12:306-317.

9. Hwang D, Wang HL. Medical con-traindications to implant therapy: Part II:Relative contraindications. Implant Dent.2007;16:13-23.

10. Hwang D, Wang HL. Medical con-traindications to implant therapy: Part I:Absolute contraindications. Implant Dent.2006;15:353-360.

11. Steigenga J, Al-Shammari K,Misch C, et al. Effects of implant threadgeometry on percentage of osseointegra-tion and resistance to reverse torque in thetibia of rabbits. J Periodontol. 2004;75:1233-1241.

12. Oh TJ, Yoon J, Misch CE, et al. Thecauses of early implant bone loss: Myth orscience? J Periodontol. 2002;73:322-333.

13. Kim Y, Oh TJ, Misch CE, et al. Oc-clusal considerations in implant therapy:Clinical guidelines with biomechanical ra-tionale. Clin Oral Implants Res. 2005;16:26-35.

14. Evans CD, Chen ST. Esthetic out-comes of immediate implant placements.Clin Oral Implants Res. 2008;19:73-80.

15. Jung RE, Sailer I, Hammerle CH, etal. In vitro color changes of soft tissuescaused by restorative materials. Int J Perio-dontics Restorative Dent. 2007;27:251-257.

16. Ochsenbein C, Ross S. A reevalu-ation of osseous surgery. Dent Clin NorthAm. 1969;13:87-102.

17. Wilderman MN, Pennel BM, KingK, et al. Histogenesis of repair followingosseous surgery. J Periodontol. 1970;41:551-565.

18. Seibert J, Lindhe J. Esthetics andperiodontal therapy. In: Lindhe J, ed. Text-book of Clinical Periodontology. Cope-nhagen: Munksgaard; 1989:477-514.

19. Claffey N, Shanley D. Relationshipof gingival thickness and bleeding to loss ofprobing attachment in shallow sites follow-ing nonsurgical periodontal therapy. J ClinPeriodontol. 1986;13:654-657.

20. Kois JC. Predictable single tooth


peri-implant esthetics: Five diagnostickeys. Compend Contin Educ Dent. 2001;22:199-206; quiz 208.

21. Kan JY, Rungcharassaeng K, Um-ezu K, et al. Dimensions of peri-implantmucosa: An evaluation of maxillary anteriorsingle implants in humans. J Periodontol.2003;74:557-562.

22. Zetu L, Wang HL. Management ofinter-dental/inter-implant papilla. J ClinPeriodontol. 2005;32:831-839.

23. Pontoriero R, Carnevale G. Surgi-cal crown lengthening: A 12-month clinicalwound healing study. J Periodontol. 2001;72:841-848.

24. Olsson M, Lindhe J, Marinello CP.On the relationship between crown form andclinical features of the gingiva in adolescents.J Clin Periodontol. 1993;20:570-577.

25. Eger T, Muller HP, Heinecke A. Ul-trasonic determination of gingival thick-ness. Subject variation and influence oftooth type and clinical features. J Clin Peri-odontol. 1996;23:839-845.

26. Hwang D, Wang HL. Flap thick-ness as a predictor of root coverage: Asystematic review. J Periodontol. 2006;77:1625-1634.

27. Gargiulo A, Wentz F, Orban B. Di-mensions and relations of the dentogingi-val junction in humans. J Periodontol.1961;32:261-267.

28. Nevins M, Skurow HM. The intra-crevicular restorative margin, the biologicwidth, and the maintenance of the gingivalmargin. Int J Periodontics RestorativeDent. 1984;4:30-49.

29. Vacek JS, Gher ME, Assad DA, etal. The dimensions of the human dentog-ingival junction. Int J Periodontics Restor-ative Dent. 1994;14:154-165.

30. Muller HP, Heinecke A, Schaller N,et al. Masticatory mucosa in subjects withdifferent periodontal phenotypes. J ClinPeriodontol. 2000;27:621-626.

31. Maynard JG Jr, Wilson RD. Physio-logic dimensions of the periodontium signifi-cant to the restorative dentist. J Periodontol.1979;50:170-174.

32. Iacono VJ. Dental implants in peri-odontal therapy. J Periodontol. 2000;71:1934-1942.

33. Cochran DL, Hermann JS, SchenkRK, et al. Biologic width around titanium im-plants. A histometric analysis of theimplanto-gingival junction around unloadedand loaded nonsubmerged implants in thecanine mandible. J Periodontol. 1997;68:186-198.

34. Abrahamsson I, Berglundh T,Wennstrom J, et al. The peri-implant hardand soft tissues at different implant sys-tems. A comparative study in the dog. ClinOral Implants Res. 1996;7:212-219.

35. Berglundh T, Lindhe J, Ericsson I, etal. The soft tissue barrier at implants andteeth. Clin Oral Implants Res. 1991;2:81-90.

36. Kan JY, Rungcharassaeng K. Sitedevelopment for anterior single implantesthetics: The dentulous site. CompendContin Educ Dent. 2001;22:221-226, 228,230-231; quiz 232.

37. Spear FM. Maintenance of the in-terdental papilla following anterior tooth re-moval. Pract Periodontics Aesthet Dent.1999;11:21-28; quiz 30.

38. Cardaropoli G, Lekholm U,Wennstrom JL. Tissue alterations at implant-supported single-tooth replacements: A1-year prospective clinical study. Clin OralImplants Res. 2006;17:165-171.

39. Blanco J, Alves CC, Nunez V, et al.Biological width following immediate im-plant placement in the dog: Flap vs. flap-less surgery. Clin Oral Implants Res. 2010;21:624-631.

40. Sanavi F, Weisgold AS, Rose LF. Bi-ologic width and its relation to periodontalbiotypes. J Esthet Dent. 1998;10:157-163.

41. Berglundh T, Lindhe J. Dimension ofthe periimplant mucosa. Biological width revis-ited. J Clin Periodontol. 1996;23:971-973.

42. Berglundh T, Abrahamsson I, We-lander M, et al. Morphogenesis of the peri-implant mucosa: An experimental study indogs. Clin Oral Implants Res. 2007;18:1-8.

43. Hermann JS, Buser D, Schenk RK,et al. Crestal bone changes around tita-nium implants. A histometric evaluation ofunloaded non-submerged and submergedimplants in the canine mandible. J Peri-odontol. 2000;71:1412-1424.

44. Tesmer M, Wallet S, Koutouzis T, etal. Bacterial colonization of the dental implantfixture-abutment interface: An in vitro study.J Periodontol. 2009;80:1991-1997.

45. Quirynen M, van Steenberghe D.Bacterial colonization of the internal part oftwo-stage implants. An in vivo study. ClinOral Implants Res. 1993;4:158-161.

46. Abrahamsson I, Berglundh T,Lindhe J. Soft tissue response to plaqueformation at different implant systems. Acomparative study in the dog. Clin Oral Im-plants Res. 1998;9:73-79.

47. Hurzeler M, Fickl S, Zuhr O, et al.Peri-implant bone level around implantswith platform-switched abutments: Prelim-inary data from a prospective study. J OralMaxillofac Surg. 2007;65:33-39.

48. Linkevicius T, Apse P, GrybauskasS, et al. The influence of soft tissue thick-ness on crestal bone changes aroundimplants: A 1-year prospective controlledclinical trial. Int J Oral Maxillofac Implants.2009;24:712-719.

49. Linkevicius T, Apse P, GrybauskasS, et al. Reaction of crestal bone aroundimplants depending on mucosal tissuethickness. A 1-year prospective clinicalstudy. Stomatologija. 2009;11:83-91.

50. Linkevicius T, Apse P, GrybauskasS, et al. Influence of thin mucosal tissueson crestal bone stability around implants

with platform switching: A 1-year pilotstudy. J Oral Maxillofac Surg. 2010;68:2272-2277.

51. Henriksson K, Jemt T. Measure-ments of soft tissue volume in associationwith single-implant restorations: A 1-yearcomparative study after abutment connec-tion surgery. Clin Implant Dent Relat Res.2004;6:181-189.

52. Bengazi F, Wennstrom JL, Lek-holm U. Recession of the soft tissue mar-gin at oral implants. A 2-year longitudinalprospective study. Clin Oral Implants Res.1996;7:303-310.

53. Chen ST, Wilson TG Jr, HammerleCH. Immediate or early placement of im-plants following tooth extraction: Review ofbiologic basis, clinical procedures, andoutcomes. Int J Oral Maxillofac Implants.2004;19 Suppl:12-25.

54. Juodzbalys G, Wang HL. Soft andhard tissue assessment of immediate im-plant placement: A case series. Clin OralImplants Res. 2007;18:237-243.

55. Paolantonio M, Dolci M, ScaranoA, et al. Immediate implantation in freshextraction sockets. A controlled clinicaland histological study in man. J Periodon-tol. 2001;72:1560-1571.

56. Botticelli D, Berglundh T, Lindhe J.Hard-tissue alterations following immedi-ate implant placement in extraction sites.J Clin Periodontol. 2004;31:820-828.

57. Araujo MG, Sukekava F,Wennstrom JL, et al. Ridge alterations fol-lowing implant placement in fresh extrac-tion sockets: An experimental study in thedog. J Clin Periodontol. 2005;32:645-652.

58. Spray JR, Black CG, Morris HF, etal. The influence of bone thickness on fa-cial marginal bone response: Stage 1placement through stage 2 uncovering.Ann Periodontol. 2000;5:119-128.

59. Chen ST, Darby IB, Reynolds EC,et al. Immediate implant placementpostextraction without flap elevation.J Periodontol. 2009;80:163-172.

60. Chen ST, Buser D. Clinical and es-thetic outcomes of implants placed inpostextraction sites. Int J Oral MaxillofacImplants. 2009;24 Suppl:186-217.

61. Chen ST, Darby IB, Reynolds EC. Aprospective clinical study of non-submerged immediate implants: Clinicaloutcomes and esthetic results. Clin OralImplants Res. 2007;18:552-562.

62. van Kesteren CJ, Schoolfield J,West J, et al. A prospective randomizedclinical study of changes in soft tissueposition following immediate and de-layed implant placement. Int J Oral Max-illofac Implants. 2010;25:562-570.

63. Romeo E, Lops D, Rossi A, et al.Surgical and prosthetic management ofinterproximal region with single-implantrestorations: 1-year prospective study.J Periodontol. 2008;79:1048-1055.


64. Choquet V, Hermans M, Adriaens-sens P, et al. Clinical and radiographic eval-uation of the papilla level adjacent to single-tooth dental implants. A retrospective studyin the maxillary anterior region. J Periodontol.2001;72:1364-1371.

65. Gastaldo JF, Cury PR, SendykWR. Effect of the vertical and horizontaldistances between adjacent implantsand between a tooth and an implant onthe incidence of interproximal papilla.J Periodontol. 2004;75:1242-1246.

66. Kan JY, Rungcharassaeng K, LozadaJL. Bilaminar subepithelial connective tissuegrafts for immediate implant placement andprovisionalization in the esthetic zone. J CalifDent Assoc. 2005;33:865-871.

67. Misch CE, Wang HL, Palti A, et al.Consensus Conference. Conference onimplant success, survival and failure the in-ternational congress of oral implantolo-gists, Pisa, Italy; 2007.

68. Bressan E, Paniz G, Lops D, et al.Influence of abutment material on the gingi-val color of implant-supported all-ceramicrestorations: A prospective multicenter study[published online ahead of print November11, 2010]. Clin Oral Implants Res. doi:10.1111/j.1600-0501.2010.02008.x.

69. Muller HP, Schaller N, Eger T. Ul-trasonic determination of thickness ofmasticatory mucosa: A methodologicstudy. Oral Surg Oral Med Oral Pathol OralRadiol Endod. 1999;88:248-253.

70. Daly CH, Wheeler JB III. The use ofultra-sonic thickness measurement in theclinical evaluation of the oral soft tissues.Int Dent J. 1971;21:418-429.

71. De Rouck T, Eghbali R, Collys K,et al. The gingival biotype revisited:Transparency of the periodontal probethrough the gingival margin as a methodto discriminate thin from thick gingiva.J Clin Periodontol. 2009;36:428-433.

72. Reddy MS, Palcanis KG, GeursNC. A comparison of manual andcontrolled-force attachment-level mea-surements. J Clin Periodontol. 1997;24:920-926.

Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Angie Lee, DMD, MS, Jia-Hui Fu, BDS,Hom-Lay Wang, DDS, MSD, PhDBiotyp des Weichgewebes beeinflusst den Implantierungserfolg

ZUSAMMENFASSUNG: Der Einfluss des Biotyps desGewebes bei der naturlichen Zahnstruktur ist bereits in derFachliteratur gut dokumentiert. Dabei weisen viele Dokumenteaus, dass dickeres Gewebe fur optimale chirurgische und pro-thetische Ergebnisse bevorzugt wird. Diesem Gedankengangfolgend, zielen aktuelle Studien darauf ab herauszufinden, in-wieweit die Dicke der Mukosa ahnliche Auswirkungen in denBereichen rund um Zahnimplantate herum hat. Dieser Berichtzielte darauf ab, die Auswirkungen des Weichgewebsbiotyps inBezug auf den Erfolg einer Implantierungstherapie zu unter-suchen. Der Einfluss des Gewebsbiotyps wurde in die nachfol-genden drei Hauptkategorien unterteilt: dessen Beziehung zurdas Implantat umgebenden Mukosa und zum darunter liegendenKnochengewebe, sofortiges Implantieren und die Wiederherstel-lungsergebnisse. Der Biotyp des Weichgewebes ist ein wichtigerParameter, der bei der Erzielung eines asthetischen Implantier-ungsergebnisses zu berucksichtigen ist. Es wird der unmittelbareImplantierungserfolg verbessert und ein zukunftiges Zuruck-weichen der Mukosa verhindert.

SCHLUSSELWORTER: Gewebsbiotyp, Gewebsdicke, Zahnim-plantat, Dicke der Mukosa, Weichgewebe, Implantierungserfolg

SPANISH / ESPAÑOLAUTOR(ES): Angie Lee, DMD, MS, Jia-Hui Fu, BDS,Hom-Lay Wang, DDS, MSD, PhDEl tipo biologico del tejido suave afecta el exito del implante

ABSTRACTO: La influencia del tipo biologico de tejido enla denticion natural ya ha sido bien demostrada en las pub-licaciones, con numerosos trabajos demostrando que el tejidomas grueso es el tipo biologico preferido para obtener resul-tados quirurgicos y prosteticos optimos. Siguiendo esa líneade pensamiento, los estudios actuales exploran si el espesorde la mucosa tiene consecuencias similares alrededor deimplantes dentales. El proposito de esta evaluacion fue in-vestigar los efectos del tipo biologico del tejido suave conrespecto al exito de la terapia de implante. La influencia deltipo biologico de tejido se dividio en tres categorías princi-pales: su relacion con la mucosa periimplante y el huesosubyacente, la colocacion inmediata del implante y los resul-tados de la restauracion. El tipo biologico del tejido suave esun parametro importante que considerar para lograr una res-tauracion estetica del implante, mejorar el exito inmediato delimplante y para prevenir la recesion futura de la mucosa.

PALABRAS CLAVES: tipo biologico de tejido, espesor deltejido, implante dental, espesor de la mucosa, tejido suave,exito del implante

PORTUGUESE / PORTUGUÊSAUTOR(ES): Angie Lee, Doutor em Medicina Dentaria, Mestreem Ciencia, Jia-Hui Fu, Bacharel em Cirurgia Dentaria, Hom-LayWang, Cirurgiao-Dentista, Mestre em Odontologia, PhDBiotipo do Tecido Mole Afeta Sucesso do Implante

RESUMO: A influencia do biotipo do tecido na denticaonatural ja esta bem demonstrada na literatura, com inumerosartigos mostrando que o tecido mais espesso e um biotipopreferido para resultados cirurgicos e proteticos otimos.Nessa mesma linha de pensamento, os estudos atuais estaovoltados para explorar se a espessura mucosal teria implica-


coes semelhantes em torno de implantes dentarios. O objetivodesta revisao era investigar os efeitos do biotipo do tecidomole em relacao ao sucesso da terapia de implante. A in-fluencia do biotipo do tecido foi dividida em tres categoriasprincipais: sua relacao com a mucosa do peri-implante e oosso subjacente, colocacao imediata de implante e resultadosrestauradores. O biotipo do tecido mole e um parametroimportante a considerar ao realizar a restauracao estetica doimplante, melhorando o sucesso imediato do implante e pre-venindo futura recessao mucosal.

PALAVRAS-CHAVE: biotipo do tecido, espessura do tecido,implante dentario, espessura mucosal, tecido mole, sucessodo implante

RUSSIAN /��: Angie Lee, �� , �� , Jia-Hui Fu, �� , Hom-Lay Wang, �� , �� , ��

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TURKISH / TURKCEYAZARLAR: Angie Lee, DMD, MS, Jia-Hui Fu, BDS, Hom-Lay Wang, DDS, MSD, PhDYumusak Dokunun Biyotipi Implant Basarısını Etkiler

OZET: Dogal dislerde doku biyotipinin etkisi literaturdekanıtlanmıs ve sayısız yazı, kalın dokunun cerrahide ve pro-tezde en iyi sonucları alma acısından tercih edilen biyotipoldugunu belirtmistir. Aynı dusunceden yola cıkanhalihazırdaki calısmalar, mukozal kalınlıgın dental implantlaruzerinde benzer etkilerinin olup olmadıgını arastırmaktadır.Bu calısmanın amacı, yumusak doku biyotipinin implant tera-pisinin basarısı uzerine etkisini degerlendirmekti. Doku biy-otipinin etkisi uc ana kategoriye ayrıldı: peri-implantmukozası ve altta yatan kemik ile baglantısı, hemen implantyukleme ile baglantısı ve restoratif sonuclar ile ilintisi.Yumusak doku biyotipi, estetik implant restorasyonusaglamak, hemen implant yukleme basarısını arttırmak veileride mukozanın geri cekilmesini onlemek icin goz onunealınacak onemli bir parametredir.

ANAHTAR KELIMELER: doku biyotipi, doku kalınlıgı,dental implant, mukoza kalınlıgı, yumusak doku, implantbasarısı


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