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Flap Designs for Minimization of Recession Adjacent to

Maxillary Anterior Implant Sites: A Clinical Study
William Becker, DDS/Burton E. Becker, DDS

The purpose of this study is to present new flap designs for the prevention of
postoperative gingival recession adjacent to maxillary anterior sites that
received dental implants. Nine patients received 10 implants in the maxillary
anterior region. Gingival morphotypes and smile lines were evaluated prior to
implant placement. Gingival probing depths, clinical attachment levels, and
recession were recorded at teeth adjacent to implant sites at the initial exam
and 3 months after implant restoration. A minimum of 5 mm of crestal bone
width was required for implant placement. The labial flaps for healed ridges
and implants placed into sockets were extended to or within 1 to 3 mm beyond
the alveolar crest. In two sites, transfer of the implant relationships was made
to provide the patients with provisional restorations at the time of second-stage
surgery. Four patients had implants placed at the time of tooth removal. In
these patients, expanded polytetrafluoroethylene barrier membranes were
modified, removing the outer rim of material. The inner portion of the material
was placed over the implant and the flaps were sutured, leaving the center part
of the material exposed. The purpose of using the barrier in this manner was to
protect the clot and subsequent granulation tissue formation during the first 2
weeks of healing. The material was removed 2 weeks after surgery. Six implants
were placed into edentulous sites. At second stage surgery, flaps were reflected
to the alveolar crest, thereby minimizing the potential for gingival recession.
Provisional restorations placed at the time of implant uncovering appeared to
support the repositioned gingiva. Changes in probing depth, clinical attachment
levels, and recession were not statistically or clinically significant. Results of this
pilot project suggest that flap designs minimized recession at teeth next to
implant sites.
(INT J ORAL MAXILLOFAC IMPLANTS 1996;11:4654)
Key words: barrier membrane, flap design, gingival morphotype, gingival recession, smile
line

Replacement of single teeth by dental implants is a viable treatment option. The

predictability of single-tooth endosseous implants to function for up to 3 years with a
98.5% success rate has been reported by Jemt and Petersen.1 The successful
application of single-tooth implants has increased patient demands for improved
esthetics in the maxillary anterior region of the mouth. Conventional implant flap
management has the risk of resulting in gingival recession around teeth adjacent to

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the edentulous ridge. To avoid recession, implant surgeons must be aware of

gingival anatomy of the adjacent teeth. Placement of implants immediately after
tooth extraction may result in gingival recession on adjacent teeth.2,3 The use of
pedicle flaps from adjacent teeth to cover implants placed immediately after tooth
extraction can be successfully used for posterior implant sites. However, the use of
this technique in the maxillary anterior region has the risk of resulting in gingival
recession at the donor site.
Ochsenbein and Ross4 described gingival contours as flat or pronounced
scalloped, with the gingiva reflecting the underlying osseous topography. A flat
periodontium is usually thick, with the gingival margins being at or coronal to the
cementoenamel junctions. A pronounced scalloped periodontium is usually thin,
with the gingival margin being at the cementoenamel junction. Patients with a thin,
scalloped periodontium may be susceptible to gingival recession. Weisgold5 related
the observations of the previous authors to crown form and tooth preparation. He
noted that recession generally occurs in patients with a thin, scalloped periodontium.
Olson and coworkers6 recently studied gingival morphotypes in adolescents. Patients
with a thin, scalloped periodontium had a narrower zone of keratinized gingiva when
compared with subjects with a flat periodontium. Furthermore, attachment loss was
greater in the group that had a scalloped periodontium. As a result of clinical
observation and information from the previously cited studies, an understanding of
gingival anatomy and bone morphology is required prior to implant placement and
particularly prior to placement of single-tooth implants in the maxillary anterior
regions.
The purpose of this study is to describe flap designs that may reduce or eliminate
gingival recession on teeth adjacent to sites receiving endosseous implants. The
effectiveness of the procedures were evaluated in terms of changes in probing depth,
probing attachment levels, and recession. Furthermore, the effectiveness of the
techniques to promote formation of gingival papillae adjacent to the implants was
evaluated.

Materials and Methods

To date, 25 consecutive patients have been treated in this study. This preliminary
report is based on nine consecutively treated patients who received 10 maxillary
single-tooth implants. The patients were referred for evaluation for either immediate
tooth removal and implant placement in the maxillary anterior region or
single-implant placement in the maxillary anterior region.
Diagnosis. All patients had complete periodontal and dental examinations and
were in good health. Clinical attachment levels were measured on the teeth adjacent
to the tooth being considered for removal or next to edentulous areas. These
measurements were made with a standardized Michigan O periodontal probe with
Williams markings periodontal probe (Hu-Friedy, Chicago). The measurements
were made from the free gingival margin to the base of the sulcus (probing depth)

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and from the cementoenamel junction or crown margin to the base of the sulcus
(probing attachment level). These measurements were taken at the initial
examination and 3 months after the implant crown restorations were placed.
The gingival tissues were classified as being thin with a pronounced scallop, or
thick with a flat gingival profile, or moderately thick. Smile lines were classified
according to Tjan and Miller.7 A high lip line resulted in complete exposure of the
teeth and gingival tissues during smiling. An average smile line revealed 75% to
100% of the maxillary anterior teeth and the interproximal papilla. A low smile
revealed less than 75% of the teeth.
Periapical radiographs were taken of the surgical area (Fig 1a). Bone quality,
bone quantity, and the distance from the alveolar crest to the floor of the nose were
determined from these radiographs. The radiographs were also used to rule out
periapical pathology and to access bone levels adjacent to the teeth. Linear
tomographs were taken to determine buccal-palatal bone width and height. A
minimum of 5 mm of bone width at the alveolar crest and 10 mm of bone height was
required for inclusion in the treatment group. Tomographs were used to determine
the presence of bone concavities, which could interfere with implant placement.
Diagnostic casts were obtained to evaluate occlusal relationships and for the
fabrication of surgical and transfer coping templates.
Surgical Technique. Immediate Implant Placement. All patients were given
detailed oral and written explanations of the procedures that were to be performed,
and each signed treatment consent forms. The patients began an established
antibiotic regimen 2 hours prior to surgery (2 g of penicillin or erythromycin 2 hours
presurgery and 1 g per day thereafter for 7 days).8 The patients were premedicated
with intravenous medications, and a local anesthetic agent was administered
(xylocaine 1:100,000 epinephrine, Astra, Rutherford, NJ). The gingival papillae
were released from the adjacent tissues with a 15C scalpel blade, and the labial flap
was extended to or slightly beyond the alveolar crest. They were released from the
adjacent teeth on the palatal aspect, creating a palatal envelope flap. An alternative
method involves creating two parallel vertical incisions on the palatal aspect and
reflecting a small full-thickness palatal flap. A full-thickness palatal flap can then be
reflected. A Molt C-2 elevator (Hu- Friedy) was used to luxate the teeth. Once the
tooth was loosened, it was removed with forceps. The socket was debrided with
periodontal curettes and files. A surgical template was seated onto the adjacent teeth.
The sites were prepared according to Adell et al.9 During drilling, light finger
pressure was applied over the buccal aspect of the surgical site. The purpose for this
was to feel for possible labial plate perforations. The decision to tap the bone was
made on the basis of bone quality. Bone quality was arbitrarily determined during
drilling. Only dense bone was tapped. When tapping was performed, only the
coronal one half of the socket was tapped. Standard 3.75-mm implants
(Nobelpharma USA, Chicago) were placed into the prepared sites under a constant

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stream of chilled sterile saline and were immobile after placement. The head of the
implant was placed parallel to the incisal edges of the adjacent teeth and was a
minimum of 2 mm below the alveolar crest10 (Fig 1b). At the coronal
bone-to-implant aspect, there were gaps between the implant and surrounding bone.
These sites were not grafted.
In two patients, implant transfer templates were used to transfer the implant
position to a cast. The casts were used to fabricate provisional restorations.11 A
cover screw was then secured to the implant head.
Oval 6 or Oval 9 barrier membranes (WL Gore, Flagstaff, AZ) were trimmed,
removing the outer nonocclusive material. The purpose of using the barrier was to
protect the blood clot surrounding the implant and to protect the granulation tissue
during the first 2 weeks of wound healing. The barriers were tucked under the labial
and palatal flap margins. Interproximal expanded polytetrafluoroethylene (e-PTFE)
sutures (WL Gore) were used to suture the interdental areas, leaving the occlusive
inner portion of the barrier membrane exposed (Fig 1c). Light gauze pressure and ice
were applied to the surgical area. At the second postoperative week, the sutures and
barriers were removed and the provisional restoration was adjusted to eliminate
pressure on the ridge tissues.
Second-Stage Surgery. The area of implant placement was photographed and
anesthetized (Fig 2a). A horizontal incision was made on the palatal aspect of the
ridge, extending from the line angles of the two adjacent teeth (Fig 2b). A USC
gingivectomy knife (Hu-Friedy) was used to dissect the tissue from the underlying
bone and to reflect the tissue to the labial alveolar crest (Fig 2c). The cover screw
was removed, the implant hex head was debrided, and either a healing abutment or a
provisional restoration was placed onto the implant head (Figs 2d and 2e). A
radiograph was taken to verify complete seating of the provisional or healing
abutments on the implant hex head. The tissues on the labial aspect were placed
slightly coronal to the gingival margins on the adjacent teeth, and interdental sutures
were placed. The sutures were removed 1 week later. Final restorations were placed
8 to 10 weeks after the second-stage procedure (Figs 2f and 2g).
Flap Design for Maxillary Anterior Region: Tooth Is Missing. The
diagnostic steps discussed above were performed in the same manner when the tooth
was missing. Figure 3a shows the linear tomograph taken during the planning stage
of treatment. The tomograph revealed a minimum of 5 mm of labial-lingual bone
width. The patient had a moderately thick periodontium (Fig 3b). The surgical
technique to achieve minimal recession involved the reflection of a curtain of tissue
from the edentulous ridge, being careful not to extend the flap more than a few
millimeters beyond the alveolar crest (Fig 3c). Implant placement followed the
standard protocol for placement into edentulous ridges. Two interrupted sutures were
placed at the line angle (Fig 3d). Figures 3e and 3f demonstrate the clinical and
radiographic appearance 1 year after loading.

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The relationship of the interproximal gingival tissues was assessed from the
clinical photographs. The existence of a dark triangle between the implant
restoration and the adjacent tooth was considered an incomplete soft tissue fill of the
interdental space.
Statistical Evaluation. The paired Student t test for a small sample size was
used to compare differences between means for teeth adjacent to the implant.
Comparisons of changes between examinations were made for probing depth,
clinical attachment levels, and recession.

Results
Of the nine treated patients (10 implants), two patients were classified as having a
thin, scalloped periodontium, six had a moderately thick gingival profile, and one
patient had a flat, thick gingival profile. Two patients had high lip lines, four patients
were classified as having average lip lines, and three patients had low lip lines (
Table 1).
Table 2 presents the data for probing depth, probing attachment level, and
recession for teeth adjacent to sites that received implants. Diffferences in probing
depths, clinical attachment levels, and recession were statistically and clinically
insignificant. At the initial examination, the mean gingival margin location for teeth
adjacent to implant sites ranged from 2.04 mm to 1.89 mm coronal to the
cementoenamel junctions. Three months after implant restoration, the mean gingival
margin location on teeth adjacent to the implants ranged from 1.97 mm to 0.67 mm.
These means indicate that there was clinically insignificant postoperative gingival
recession and that the gingival margins adjacent to the teeth remained coronal to the
cementoenamel junctions postsurgery.
Four implants were augmented with e-PTFE barrier membranes for the purpose
of promoting gingival coverage of the exposed implant head. At the second stage,
the implants were completely covered by gingival tissue, and bone had filled the
small gaps between the implants and surrounding bone.
Of the 10 implants, two received provisional restorations at the second-stage
surgery. One patient received the final restoration at the second-stage visit. The
remaining seven implants had healing abutments placed at the second stage and
received provisional restorations within 3 to 6 weeks following the second-stage
procedures.
Table 3 describes the relationship of the interproximal gingival tissues to the
implant-retained crowns. Gingiva filled the interimplant embrasures at six of the 10
implant sites. The patients were examined 1 year after implant loading and
radiographs were taken. Figures 2f and 3e were taken 1 year after loading. It can be
seen that the gingival tissues adjacent to the implants are even with the adjacent
teeth. There was no loss of implants at the 1 year evaluation, and the location of the

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gingival margins in relation to the implant restorations and adjacent teeth were
unchanged from the 3-month examinations.

Discussion
The 10 implants reported in this pilot project have been loaded for more than 1 year
and have demonstrated no clinically significant evidence of gingival recession on the
teeth adjacent to the implants. Changes between probing depth and clinical
attachment levels were statistically and clinically insignificant. These preliminary
results for a limited sample size provide data that indicate that the flap designs were
effective in eliminating postoperative gingival recession on teeth next to the implant
sites. Prior to surgery, the patients gingival profile and smile lines were evaluated to
attempt to identify patients who could be susceptible to gingival recession. The
surgical technique necessary to predictably reduce gingival recession in patients with
varying gingival morphotypes requires a minimum of 5 mm of bone width at the
alveolar crest and a minimum of 10 mm of bone height. The labial flaps were not
extended more than 1 to 3 mm beyond the alveolar crest. Use of conservative flap
designs may have eliminated postoperative gingival recession on the adjacent teeth.
This was noted in the clinical documentation and by comparing the preoperative and
postoperative clinical measurements.
At the initial exam, the average gingival margin location for teeth adjacent to the
implant sites ranged from 1.89 mm to 2.04 mm coronal to the cementoenamel
junction. At the second-stage surgery, the gingival margins remained coronal to the
cementoenamel junctions. Gingival recession frequently occurs after periodontal
surgery. Isidor et al12 reported an average of 2.5 mm of recession after periodontal
surgery and 1.8 mm after scaling and root planing. At 6 months and 1 year
postsurgery, Becker and coworkers13 reported significant recession after treatment of
4- to 6-mm probing depths with osseous surgery and modified Widman procedures.
These recession changes ranged from 1.25 mm for osseous surgery and 1.05 mm for
the modified Widman procedures. These types of procedures involved flap elevation
to or beyond the mucogingival junction. In the present study, labial flaps were
reflected to the alveolar crest, and these types of incisions may have contributed to
the insignificant changes in gingival margin positions on the teeth adjacent to the
implants.
Lazzara2 reported on the use of e-PTFE barrier membranes for the promotion of
bone adjacent to immediately placed implants. The barrier membranes were not
covered by the flaps and were frequently removed several weeks after placement. At
second-stage surgery, bone was clinically evident around the previously augmented
implants. The e-PTFE barrier membranes were used to protect the clot and to
promote undisturbed epithelialization over the implants. The biologic rationale for
this procedure has not been evaluated in a controlled environment but appears to be
clinically effective. At second-stage surgery, the small bony gaps that were initially
present adjacent to the implants had filled in with bone. This observation supports
2

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the earlier report of Lazzara2 and may indicate that retention of barrier membranes
for the entire healing period may not be necessary. Simeon et al14 has recently
reported the results of exposing the inner portion of e- PTFE barrier membranes to
bacterial contamination. Scanning electron microscopy demonstrated that at 1 week,
the inner part of the e-PTFE barriers is totally occlusive to bacterial penetration.
Landsberg and Bichacho15 have recommended covering extractions sockets that
received immediate implants with small free gingival grafts. One of the
disadvantages of this technique is the necessity to obtain the gingival graft from a
second surgical site. Preliminary evaluation of this procedure indicates that it
produces acceptable esthetic results.
Fabrication of esthetic implant-supported crown restorations in the maxillary
anterior region is a demanding procedure. The surgeon, the restorative dentist, and
the laboratory technician must attempt to create gingival tissue between the implant
and the adjacent tooth. Creating an illusion of a papilla within the interproximal
space requires expanding the gingival cuff adjacent to the implant and
overcontouring the final restoration to support the laterally positioned tissue. To
date, there are no data relating to the predictability of these procedures. In this study,
the illusion of an interproximal papilla was created in five of the six sites that
initially had moderately thick tissues with moderate gingival scallop.
The profession has become obsessed with eliminating small dark spaces between
implants and adjacent teeth. Casual observation of tooth-supported fixed partial
dentures in the maxillary anterior region frequently reveals small, dark, triangular
interdental spaces. In adults, in many instances this appears natural. By displacing
the gingival tissues adjacent to implants laterally and placing overcontoured
restorations into the sulcus, we may be creating hygiene and other, as yet
undetermined, peri-implant problems.
There are differences of opinion relating to implant placement in the maxillary
anterior region. Shanaman16 placed implants in labial positions to achieve an optimal
esthetic result. Placement of implants in labial positions frequently resulted in bony
dehiscences of the labial plate. These defects were grafted with demineralized
freeze-dried bone and barrier membranes. Saadoun et al17 suggested that the long
axis of a single-tooth implant approximates the emergence profile of a single tooth.
This position places the head of the implant in a labial position and frequently results
in defects that require grafting and barrier augmentation. Gelb and Lazzara18
recently related implant placement to the amount of remaining bone. They suggested
that angled abutments and copings are frequently required to correct implant
emergence profiles. In this study, the shape of the bone in the maxillary anterior
region dictated the emergence angle of the implant. The head of the implant was
parallel to the incisal edges of the adjacent teeth, while the axis of the implant body
was inclined palatally. Placement of the implants in this position did not compromise
the labial plate, and all implants were restored with standard prosthetic components

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(CeraOne, Nobel pharma). One of the disadvantages of utilizing minimal flap

designs is the inability to determine when bone fenestrations occur during implant
site preparation. The frequency of labial plate fenestration with the flap designs
presented in our study are unknown.
Utilization of templates to transfer implant relationships to working casts
provided an effective method-for providing provisional restorations at the
second-stage surgery.11 This method, together with retention and careful positioning
of the retained keratinized gingiva at the second stage, may have helped eliminate
gingival recession adjacent to the implant sites. The provisional restorations
appeared to support the repositioned gingival tissues.

Conclusion
The short-term results of using flap designs described in this study suggest that
postoperative gingival recession at implant sites and on adjacent teeth can be
significantly minimized. The use of the inner portion of the e-PTFE barriers may
have protected the clot over the implant, resulting in undisturbed wound
epithelialization. Placement of provisional restorations at second-stage surgery may
support the newly positioned gingival margins and contribute to maintenance of the
gingival position in relation to the adjacent teeth.

Acknowledgments
The authors gratefully thank Drs Clifford Ochsenbein, Arnold Weisgold, and
Patrick Henry for their advice and encouragement during the preparation of this
report. Many of the ideas expressed in this report were developed with the North
American Periodontal Study Group.

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1. Jemt T, Petersen P. A 3 year follow-up study of single implant treatment. J Dent

1993;21:203208.
2. Lazzara R. Immediate implant placement into extraction sites: Surgical and
restorative advantages. Int J Periodont Rest Dent 1989;9:333343.
3. Becker W, Becker BE. Guided tissue regeneration for implants placed into
extraction sockets and for implant dehiscences: Surgical techniques and case
reports. Int J Periodont Rest Dent 1990;10:377391.
4. Ochsenbein C, Ross S. A reevaluation of osseous surgery. In: Dental Clinics of
North America. Philadelphia, PA: Saunders, 1969:87102.
5. Weisgold A. Contours of the full crown restoration. Alpha Omegan 1977;10:7789.
6. Olson M, Lindhe J, Marinello CP. On the relationship between crown form and
clinical features of the gingiva in adolescents. J Clin Periodontol 1973;20:570
577.
7. Tjan AHL, Miller GD. Some esthetic factors in a smile. J Prosthet Dent 1985;51:24
28.
8. Classen DC, Scott RE, Restotnik SL, Horn SD. The timing of prophylactic
administration of antibiotics and the risk of surgical-wound infection. New Eng J
Med 1992;326(5):281286.
9. Adell R, Lekholm U, Rocker B, Brnemark P-I. A 15 year study of osseointegrated
implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387
416.
10. Parel S, Sullivan D. Esthetics and Osseointegration. Guidelines for Optimal
Fixture Placement. An Osseointegrated Seminars Inc Publication, 1989;1928.
11. Riser GM, Dornbush JR, Cohen R. Initiating restorative procedures at the
first-stage implant surgery with a positional index: A case report. Int J Periodont
Rest Dent 1992;12:279293.
12. Isidor F, Karring T, Attstgrom R. The effect of root planing as compared to that of
surgical treatment. J Clin Periodontol 1984;11:669673.
13. Becker W, Becker BE, Ochsenbein C, Kerry G, Caffesse R, Morrison ED, Prichard
J. A longitudinal study comparing scaling, osseous surgery and modified
Widman procedures. Results after one year. J Periodontol 1988;59:351365.
14. Simeon M, Baldoni M, Rossi P, Zaffe D. A comparative study of the effectiveness
of e-PTFE membranes with and without early exposure during the healing
period. Int J Periodont Rest Dent 1994;14:167180.
15. Landsberg CJ, Bichacho N. A modified surgical/prosthetic approach for optimal

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single implant supported crown. Part IThe socket seal surgery. Pract
Periodontics Aesthet Dent 1994;6(2):1117.
16. Shanaman RH. The use of guided tissue regeneration to facilitate ideal prosthetic
placement of implants. Int J Periodont Rest Dent 1992;12;257265.
17. Saadoun AP, Sullivan DY, Krischek M, Gall M. Single tooth implant management
for success. Pract Periodontics Aesthet Dent 1994;6(3);7380.
18. Gelb DA, Lazzara RJ. Hierarchy of objectives in implant placement to maximize
esthetics: Use of pre-angled abutments. Int J Periodont Rest Dent 1993;13;277
287.

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Fig. 1a Radiograph demonstrating a crown fracture of

the maxillary right central incisor.

Fig. 1b The socket is debrided

with periodontal curettes and files, and the labial and palatal flap margins are extended
slightly beyond the alveolar crest. A 3.75-mm implant is placed into the extraction socket
and the head of the implant is slightly below the alveolar crest. Note the bone defect on
the labial, mesial, and distal implant aspects.

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Fig. 1c The inner portion of an

e-PTFE barrier is placed beneath the buccal and palatal flap margins. The sutures and
barrier are removed 2 weeks after surgery.

Fig. 2a Six-month postsurgery

evaluation. Note complete soft tissue healing over edentulous ridge.

Fig. 2b A USC periodontal knife is

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used to reflect the ridge tissue toward the labial crest.

Fig. 2c The ridge tissue is reflected

to the labial alveolar crest, and the implant head is exposed.

Fig. 2d A provisional restoration is

placed, and the flap margins are positioned and sutured slightly coronal to the adjacent
teeth.

Fig. 2e A provisional restoration was

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placed at the time of the second-stage surgery.

Figs
2f and 2g One-year evaluation of implant and soft tissue health. Note absence of
recession on adjacent teeth. (Restorative dentistry, John Doerr, DDS.)

Fig. 3a A linear tomograph of the left

edentulous lateral incisor region. There is 5 mm of labial-palatal width at the crest, and
this dimension broadens superiorly.

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Fig. 3b Preoperative view. Patient

has moderately thick gingiva and a flat gingival profile. The smile line reveals all of the
anterior teeth and the gingival papilla.

Fig. 3c A flap is raised to the labial

aspect and is extended slightly beyond the alveolar crest. A 3.75-mm Nobelpharma
implant has been placed into the prepared site. The head of the implant is located
slightly apical to the alveolar crest.

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Fig. 3d The flap margins are closed

with interrupted sutures.

Fig. 3e One-year follow-up of

implant and gingival tissues. Note absence of recession on adjacent teeth. (Restorative
dentistry, Kent Banta, DDS.)

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Fig. 3f Radiograph at 1-year implant evaluation visit.