Soft Tissue Biotype Affects

Implant Success
Angie Lee, DMD, MS,* Jia-Hui Fu, BDS, and Hom-Lay Wang, DDS, MSD, PhD
T
he extensive scientific literature
published in the field of implan-
tology offers a plethora of criteria
to define implant success.
13
Examples
of traditional clinical parameters used to
measure success include marginal bone
loss, sulcus depth, and mobility. Re-
cently, the agreement among the
International Congress of Oral Implan-
tologists is that a successful implant
should fulfill both functional and esthetic
criteria.
4
Appraisal of esthetics is an im-
portant aspect that entails personal eval-
uation of the conformity of the orofacial
complex to the community standard of
beauty, with achievement of an im-
proved smile and self-image.
5
A suc-
cessful esthetic outcome ultimately lies
in the perception of the patient. How-
ever, for the clinician, assessment of es-
thetic outcomes is performed through
examination of clinical parameters, such
as level of soft tissue margin, interprox-
imal papillae, and color blend of the
prosthesis with the natural dentition.
6,7
Multiple biological and biome-
chanical factors have been reported to
adversely affect implant success, for
instance the use of tobacco and the pres-
ence of occlusal overload.
813
More re-
cently, tissue thickness has also been
reported to be an important factor that
influences implant success.
6,14,15
As far back as the late 1960s, stud-
ies already reported a positive surgical
benefit with thicker soft and hard tis-
sues.
16,17
Nonetheless, it was only later
that the term periodontal biotype was
first coined by Seibert and Lindhe.
18
In
natural teeth, these authors observed that
a thick-flat periodontal biotype was as-
sociated with quadratic teeth and wide
zones of keratinized gingiva. On the
other hand, a thin-scalloped periodontal
biotype was associated with slender
teeth, which presented with narrow zones
of keratinized gingiva. These previous ob-
servations made in the late 1980s were
highly subjective leading other authors to
quantify gingival thickness in relation to
periodontal inflammation; these authors
defined thin gingival tissues as 1.5 mm
and thick gingival tissues as 2.0 mm.
19
Looking into the evidence available, one
can gather that thick biotypes have a flat
architecture and, when subjected to me-
chanical and/or surgical trauma, are inher-
ently more resistant to recession leading to
formation of periodontal pockets and infr-
abony defects. In contrast, thin biotypes
have a scalloped appearance and respond
readily to mechanical insults with gingival
recession.
2025
Furthermore, a systematic
review conducted by Hwang and Wang
26
well demonstrated the importance of a
minimal flap thickness to achieve com-
plete root coverage around teeth.
Extrapolating the observations of
soft tissue behavior around natural teeth,
the periimplant soft tissue can also be
categorized into thin and thick biotypes.
However, definitions of this classifica-
tion varied among different studies. Ac-
cording to Kan et al
21
, a thin biotype is
one where the outline of the periodontal
probe can be seen through the marginal
tissue when probing, whereas a thick
biotype is one where the probe is cam-
ouflaged by the marginal tissue. Similar
to gingival tissue, thin periimplant soft
tissue is more susceptible to soft tissue
recession compared with thick periim-
plant soft tissue.
14
This feature can be
attributed to thinner tissues being more
friable, less vascularized, and accompa-
*Adjunct Clinical Assistant Professor and Research Fellow,
Department of Periodontics and Oral Medicine, School of
Dentistry, 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, Department
of Periodontics and Oral Medicine, School of Dentistry,
University of Michigan, Ann Arbor, MI.
Research Advisor, Eng. A.B. Research Chair for Growth
Factors and Bone Regeneration, King Saud University Riyadh,
Saudi Arabia.
Reprint requests and correspondence to: Hom-Lay
Wang, DDS, MSD, PhD, Department of Periodontics
and Oral Medicine, University of Michigan School of
Dentistry, 1011 North University Avenue, Ann Arbor,
MI 48109-1078, Phone: 734763.3383, Fax:
734936.0374, E-mail: homlay@umich.edu
ISSN 1056-6163/11/02003-038
Implant Dentistry
Volume 20 Number 3
Copyright 2011 by Lippincott Williams & Wilkins
DOI: 10.1097/ID.0b013e3182181d3d
The influence of tissue biotype in
natural dentition is already well dem-
onstrated in the literature, with nu-
merous articles showing that thicker
tissue is a preferred biotype for opti-
mal surgical and prosthetic outcomes.
In this same line of thought, current
studies are directed to explore
whether mucosal thickness would
have similar implications around den-
tal implants. The purpose of this re-
view was to investigate the effects of
soft tissue biotype in relation to suc-
cess of implant therapy. The influence
of tissue biotype was divided into 3
main categories: its relationship with
periimplant mucosa and the underly-
ing bone, immediate implant place-
ment, and restorative outcomes. Soft
tissue biotype is an important param-
eter to consider in achieving esthetic
implant restoration, improving imme-
diate implant success, and preventing
future mucosal recession. (Implant
Dent 2011;20:e38e47)
Key Words: tissue biotype, tissue
thickness, dental implant, mucosal
thickness, soft tissue, implant success
e38 SOFT TISSUE BIOTYPE AFFECTS IMPLANT SUCCESS LEE ET AL
nied with thinner underlying bone.
20
In
implantology, the importance of a thick
biotype is further reinforced because of
the lack of a periodontal ligament that
provides additional blood supply during
wound healing. Therefore, it appears
reasonable that thick tissue would be a
desirable feature around dental implants
both 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 article
was to clarify the role of periimplant
tissue biotype in various implant suc-
cess criteria. The effect of tissue bio-
type in implant therapy was divided
into 3 main categories: its relationship
with periimplant mucosa and the un-
derlying bone, immediate implant
placement, and restorative outcomes.
RELATIONSHIP OF TISSUE
BIOTYPE WITH PERIIMPLANT
MUCOSA AND THE
UNDERLYING BONE
In natural dentition, biologic width,
or more properly named biologic height,
refers to the dentogingival junction in-
cluding epithelial attachment (0.97
mm), supracrestal connective tissue
(1.07 mm) and, arguably, gingival
sulcus (0.69 mm).
27,28
The results of
studies conducted on cadavers show
great individual variations in bio-
logic width, especially in regard to epi-
thelial attachment (1.09.0 mm)1.
27,29
To explain this wide range of measure-
ments, Muller et al
30
proposed that a
thin periodontal biotype is associated
with a shallower biologic width
compared with a thick biotype. As a
consequence, a thin biotype is more
susceptible to biologic width inva-
sion resulting in marginal tissue re-
cession and alveolar bone loss.
31
The equivalent term for biologic
width around dental implants is periim-
plant mucosa.
21,32
Fundamental differ-
ences exist between periimplant mucosa
and its counterpart in natural teeth. For
instance, the attachment apparatus is lo-
cated subcrestal around implants but su-
pracrestal around teeth. Moreover, as
demonstrated in animal studies, the av-
erage periimplant mucosal dimension
was 3 mm, which was 1 mm more than
that of natural teeth.
3335
Periimplant mucosal dimensions
varied according to soft tissue biotype.
Kan et al evaluated dimensions of the
periimplant mucosa by bone sounding
around restored implants in humans, and
reported consistently greater values in
thick biotype compared with thin bio-
type, although no significant differences
were noted at the facial and distal areas
of the implant. A periimplant mucosal
dimension at the facial aspect of 3 mm
was associated with a thin biotype, la-
bioversion of the implant and/or over-
contoured facial emergence of the
crown. Conversely, thick biotypes were
associated with a periimplant mucosal
dimension of 4 mm at the facial as-
pect. As a consequence, implants may
be prone to papilla loss when the dis-
tance from the tip of the papilla to the
underlying bone of the adjacent natural
tooth is larger than 4 mm in a thin
biotype. In comparison, thick biotype
experienced less papilla loss even at a
distance of 4.5 mm from the papilla tip
to the underlying bone crest.
21
To main-
tain the integrity of this papilla after
tooth extraction, clinicians should con-
sider to restore the papilla before tissue
collapse.
36,37
One advantageous feature
is 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 mean
epithelial and connective tissue attach-
ment in thin and thick tissue biotypes.
34
Because definitions of thin and thick
tissues were not provided in the latter
study, comparison with other studies
was not possible. Furthermore, histolog-
ical measurements of the attachment in
animals may yield different values from
bone sounding techniques performed in
humans. In the study by Abrahamsson et
al, implants were not restored, and
therefore, results obtained can only be
interpreted as the periimplant mucosa
before occlusal loading.
When evaluating periimplant tis-
sue dimensions around immediate
implants, dimensions on the buccal
aspect were significantly higher in
implants placed after a conventional
flap surgery compared with a flap-
less surgical technique (3.69 mm vs
3.02 mm, respectively). This differ-
ence was particularly observed in
areas with a thin biotype, which sug-
gests that flapless implant placement
can help with the reestablishment of
a smaller periimplant mucosa.
39
A minimum dimension of periim-
plant mucosa is necessary to maintain
health. Similar to natural teeth, inva-
sion of the periimplant mucosa causes
periimplant tissue inflammation and
crestal bone loss.
34,4042
As a result of
this impingement and to reestablish
the mucosal dimension, angular defect
was characteristic of a thin mucosa,
whereas thicker tissues demonstrated
horizontal bone loss.
34,41
The interpretation of the results
from multiple studies attribute early
crestal bone loss to the location of the
microgap at the implant-abutment in-
terface, which contributes to increased
microbial invasion, inflammatory cell
infiltrate, and mechanical stress to the
crestal bone.
4346
Although still debat-
able, some authors advocate displace-
ment of the implant-abutment interface
away from crestal bone by means of
platform switching or supracrestal im-
plant placement to prevent early bone
loss.
47
Two reports showed the correla-
tion between tissue biotype and crestal
bone loss in nonsubmerged implants.
48,49
When implants were placed 2 mm su-
pracrestally, subjects with a thin mucosa
exhibited significantly greater mean cr-
estal bone loss than subjects with a me-
dium (ie, tissue thickness of 2.13.0
mm) and thick (ie, tissue thickness of
3.1 mm) biotypes (P 0.05). In the
control group where implants were
placed at the bone level, tissue biotype
did not affect mean crestal bone loss.
The authors did not recommend supra-
crestal implant placement in sites with
thin mucosa due to increased crestal
bone loss compared with a thicker bio-
type. Nonetheless, further examination
is warranted because this crestal bone
loss was comparable with the control
group where implants were placed at the
bone level. Moreover, in patients with
thin biotype, implants with platform
switching failed to maintain crestal bone
level, 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 soft
and hard tissue resorption to reestablish
a healthy periimplant mucosal dimen-
sion, especially in a thin biotype.
34
Interestingly, periimplant tissue
thickness is a dynamic entity reflected in
that following crown placement, the fa-
cial mucosa of the implant increased in
thickness even though a slight remission
was observed at 1-year examination.
38,51
In addition, soft tissue recession of 0.6
mm was noted on the labial surface
along with this remission, which may be
attributed to the establishment of an ad-
equate periimplant mucosal dimen-
sion.
52
Another important finding is that
mucosal thickness was related to the
height of the free marginal tissue in a
1:1.5 ratio.
38
The literature reviewed in this sec-
tion provided insight in regard to the
relation of periimplant mucosa and cr-
estal bone loss with tissue thickness
measured before implant placement
4850
and after implant restoration
21
(Table 1,
Fig. 1). Periimplant mucosa typically
measures 3 mm in a thin tissue bio-
type compared with more than 4 mm in
a thick tissue biotype. Because of the
increased susceptibility to mucosal re-
cession and crestal bone loss in a thin
biotype, platform switching failed to
maintain soft and hard tissue levels. Fu-
ture studies on a large patient population
will be needed to explore the effect of
platform switching on a thick biotype.
ROLE OF TISSUE BIOTYPE
IN IMMEDIATE
IMPLANT PLACEMENT
Immediate implant placement re-
fers to implants placed at the time of
tooth extraction. Albeit its demonstrated
success rate
53,54
and its key advantage of
a shortened treatment time, immediate
implant placement is a technique-
sensitive procedure that requires de-
tailed evaluation of hard and soft tissue
components. In the past, immediate
implant placement was thought to min-
imize physiologic bone loss that accom-
panied remodeling of the extraction
socket.
55
It is now known that the pro-
cess of bone remodeling is an unavoid-
able phenomenon
56,57
and, therefore,
understanding bone and soft tissue re-
modeling helps to achieve more predict-
able esthetics and treatment success in
immediate implant placement.
The critical gap distance, deter-
mined to be 1 to 2 mm, refers to the
residual defect between the implant and
bone, and dictates the necessity of
placing a bone graft and/or barrier mem-
brane.
53
Furthermore, a minimum resid-
ual buccal bone thickness of 1 to 2 mm
is necessary for maintenance of the bone
level, a threshold below which hard tis-
sue augmentation is recommended.
54,58
Likewise, soft tissue thickness is also a
critical parameter to consider and can
influence the level of marginal tissue
and presence of papilla in immediate
implant placement.
A total of 5 studies evaluated tissue
biotype around immediately placed im-
plants, of which 3 were prospective
studies (Table 2). In these studies, pa-
tients with thin biotype showed in-
creased mucosal recession in immediate
implant placement compared with those
with thick biotype who showed less re-
cession.
59,60
In a retrospective study, Ev-
ans and Chen
14
reported 0.9 0.78 mm
of mucosal tissue recession after 18.9
months of function with no significant
differences between the 2 investigated
Table 1. Studies That Correlated Tissue Biotype With Periimplant Mucosa and the Underlying Bone
Study Study Design N Site
Definition of
Biotype
Time of
Measurement
Implant
System
Observation
Period
No. of
Stages
Types of
Prosthesis
Abrahamsson
et al
34
Animal 5 Beagle dogs Mandibular
premolars
Undefined Abutment Brnemark vs
Astra Tech
vs Bonefit
6 mo 1 and 2 Abutment
connection
and
extension
caps
Prospective 30 Implants
Berglundh and
Lindhe
41
Animal 5 Beagle dogs Mandibular
premolars
Thin: 2.4 mm Abutment Brnemark 6 mo 2 Abutment
connection
Prospective 30 Implants Thick: 3.3 mm
Kan et al
21
Retrospective 45 Patients
45 Implants
Maxillary
anteriors
Thin: probe seen
through tissue
After prosthesis Unknown 1 yr 2 Single crowns
Thick: probe not
seen through
tissue
Cardaropoli
et al
38
Prospective 11 Patients Maxillary
anteriors
Ultrasonic Abutment
connection
Brnemark 1 yr 2 Single crowns
11 Implants
Linkevicius
et al
48
Prospective 26 Patients
64 Implants
Unknown Thin: 2 mm
Medium: 2.13
mm
Thick: 3.1 mm
Implant
placement
BioHorizons 1 yr 1 Single crowns
and fixed
partial
denture
Linkevicius
et al
49
Prospective 19 Patients
46 Implants
Unknown Thin: 2 mm
Thick: 2.5 mm
Implant
placement
BioHorizons 1 yr 1 Single crowns
and fixed
partial
denture
Linkevicius
et al
50
Prospective 4 Patients Unknown Thin: 2 mm Implant
placement
3i BioHorizons 1 yr 1 Splinted crowns
and fixed
partial
denture
12 Implants
Blanco et al
39
Animal 5 Beagle dogs Mandibular
premolars
Undefined Unknown Straumann 3 mo 1 Abutment
connection
Prospective 20 Implants
e40 SOFT TISSUE BIOTYPE AFFECTS IMPLANT SUCCESS LEE ET AL
implant systems (Straumann vs 3i). The
authors found that areas with a thin tis-
sue biotype featured increased tissue re-
cession compared with a thick tissue
biotype (1.0 0.9 mm vs 0.7 0.57
mm, respectively), although the results
did not reach statistical significance.
However, it is important to note
that a previous study published by
Chen et al
61
did not find any rela-
tionship between tissue biotype and
recession in immediate implant
placement. Furthermore, a recent
study examined soft tissue changes
in immediate implants compared
with delayed implants. The authors
reported favorable clinical outcomes
in both groups with no significant
effect of tissue biotype on the
changes in soft tissue position.
62
The conflicting data of the above-
mentioned reports regarding tissue
biotype on soft tissue recession in im-
mediate implants may be attributed to a
sample population with a particularly
small number of sites with recession ob-
served both in the study by Chen et al
61
and van Kesteren et al.
62
Although there
are studies that show contradictive re-
sults, the overall conclusion would lead
us to believe that soft tissue biotype
plays an influential role in immediate
implant placement especially in sites
that show specific predisposition to soft
tissue recession. For example, when the
implant was placed facially, 85.7% (6/7)
of thin biotypes had 1 mm of reces-
sion compared with 66.7% (2/3) in thick
biotypes.
14
Moreover, in the study by
van Kesteren et al, the lack of a defini-
tion for tissue biotype and placement of
bone grafts in immediate implant sites
make the comparison with other studies
more difficult.
After the analysis of how a thin
biotype poses a risk of increased muco-
sal recession, there is also evidence to
support that a thin biotype is associated
with increased susceptibility to loss of
papilla in immediate implants. In a pro-
spective study, Romeo et al
63
placed 48
nonsubmerged immediate implants con-
nected with a transmucosal healing
screw. A dichotomous scale was used to
identify the presence or absence of pa-
pilla. The results show that thick tissue
biotype was significantly associated
with 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 Site
Definition of
Biotype
Time of
Measurement
Implant
System
Observation
Period
No. of
Stages
Types of
Prosthesis
Chen et al
61
Prospective 30 Patients
30 Implants
Maxillary anterior
and premolars
Undefined At second stage
surgery
Straumann 34 yr 2 Single crown
Evans and
Chen
14
Retrospective 42 Patients
42 Implants
Maxillary and
mandibular
anterior and
premolars
Thin: probe seen
through labial
tissue
After prosthesis 3i, Straumann 18.9 mo
(650
mo)
Unknown Single crown
Thick: probe not
seen through
Romeo
et al
63
Prospective 48 Patients
48 Implants
Maxillary and
mandibular
anterior and
premolar
Thin: Probe seen
through labial
tissue
After prosthesis Straumann 1 yr 1 Single crown
Thick: probe not
seen through
Chen et al
59
Retrospective 85 Patients
85 Implants
Maxillary incisors Thin 1 mm Surgery Straumann 1 yr 1 Single crown
Thick 1 mm
van Kesteren
et al
62
Prospective 24 Patients
26 Implants
Maxillary anteriors;
maxillary and
mandibular
premolars
Undefined Unknown Straumann 6 mo 1 Unknown
IMPLANT DENTISTRY / VOLUME 20, NUMBER 3 2011 e41
contact point was 3 to 7 mm from the
bone crest (P 0.05), a finding substan-
tiated by previous reports in the litera-
ture.
64,65
The presence of papilla was
observed in 84% of subjects with thick
biotype compared with 42.8% of sub-
jects with thin biotypes.
63
Thick biotype is associated with a
rather flat architecture suggesting the
presence of a shorter papilla height
compared with longer papilla in the
thin biotype. In areas of high esthetic
demands and for subjects with thin
biotype, soft tissue enhancement is
beneficial to maintain and reconstruct
adequate papilla height if immediate
implant placement is considered.
66
Al-
ternatively, loss of papilla can be cam-
ouflaged by modifying the shape and
contour of the prosthesis. This can be
achieved by positioning the contact
point in a more apical position, and by
favoring rectangular over triangular
crown shapes.
6
RELATIONSHIP OF
TISSUE BIOTYPE WITH
RESTORATIVE OUTCOMES
Esthetic outcomes have gained in-
creasing importance and are now in-
corporated as a parameter of implant
success.
67
The grayish shadow shown
through the tissue is a major disadvan-
tage of titanium implants with metal
abutments and a source of undesirable
esthetics. In an in vitro study where
tissue color changes were measured
utilizing a spectrophotometer, the au-
thors found that zirconia did not
induce color changes visible to the
human eye in mucosal thickness of 2
to 3 mm, whereas titanium produced
the most color changes for the same
mucosal 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 tissue
thickness was not correlated with the
degree of color changes induced by
different abutment materials. How-
ever, while all 3 materials induced
color changes in periimplant soft tis-
sues, titanium abutments produced
significantly greater color changes on
soft tissues compared with gold and
zirconium oxide abutments.
68
The conflicting conclusions ob-
tained by Jung et al and Bressan et al
in regard to the effect of abutment
materials on soft tissue thickness may
be attributed to the differences be-
tween in vivo and in vitro studies. In
the study by Bressan et al, none of the
subjects displayed a tissue thickness
3 mm. Because soft tissue thickness
in vivo does not typically measure
above 3 mm, zirconium abutments are
preferred for both biotypes in the es-
thetic zone to minimize color changes
in the mucosa and maximize esthetic
results (Fig. 1, Table 3).
CURRENT LIMITATIONS AND
FUTURE DIRECTIONS
Drawbacks of existing studies in-
clude the limited sample size and het-
erogeneity in study methodology. The
heterogeneity in methodology of the
studies requires exerting caution when
interpreting the results. The lack of a
consensus among the various studies
in the definition of tissue biotype con-
stitutes an important matter. Several
authors considered the tissue thin
when the transparency of the peri-
odontal probe can be seen through the
sulcus, whereas they were considered
thick when the probe cannot be
seen.
14,21
However, other authors de-
fined a thin biotype as a tissue thick-
ness measurement of 1 to 2 mm, and
that of a thick biotype as 1 to 2
mm.
48,60
In the study by Chen et al, the
authors measured tissue biotype by de-
termining the width of keratinized tis-
sue; for example, a width of keratinized
tissue of 5 mm is categorized as a thin
biotype, whereas a width of keratinized
tissue of 5 mm is defined as a thick
biotype, as referenced by Muller et
al.
30,59
In addition, the area where tissue
thickness was measured also varied
from one study to the other.
The method used to assess tissue
thickness differed greatly among stud-
ies. The report by Jung et al measured
tissue thickness using a caliper,
15
whereas Linkevicius et al measured tis-
sue thickness using a periodontal probe
with direct visual assessment before el-
evating the buccal flap.
48
The use of
ultrasonics to measure tissue thickness is
also a valid and reliable method.
25,69
Nonetheless, the additional cost and
technical difficulty of working with the
transducer have limited the practicality
of 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. An
intraexaminer reproducibility of 85%
has been reported, which confirms the
clinical use of this method (k 0.70;
P 0.002).
71
The authors of the latter
study believed that an accurate and ob-
jective assessment of tissue biotype
should be based on direct soft tissue
thickness measurement using a peri-
odontal probe or an endodontic file.
Nonetheless, it is important to highlight
limitations associated with this tech-
nique such as the necessity of local an-
esthesia, and the variations associated
with probe angulation and pressure.
Furthermore, the accuracy of the North
Carolina periodontal probe is limited be-
cause its resolution is 1 mm.
72
Despite
these drawbacks, these techniques allow
Table 3. Studies That Correlated Tissue Biotype With Restorative Outcomes
Study
Study
Design N Site
Definition of
Biotype
Time of
Measurement
Implant
System
Observation
Period
No. of
Stages
Types of
Prosthesis
Jung et al
15
In vitro 10 Pig maxillae Palatal
mucosa
Thickness of
1.5, 2.0, and
3.0 created
NA NA NA NA NA
Bressan
et al
68
Prospective 20 Patients Maxillary
anteriors
Thin: 2 mm On cast Astra Tech NA 2 Single crown
Thick: 2 mm
NA, not applicable.
e42 SOFT TISSUE BIOTYPE AFFECTS IMPLANT SUCCESS LEE ET AL
clinicians to have an acceptable estima-
tion of the thickness of tissues.
In a recent study applying cluster
analysis, 100 patients were divided
into 3 categories: thin-scalloped,
thick-flat, and thick-scalloped. Both
experienced and inexperienced clini-
cians were asked to visually assess
tissue biotypes. Experienced clinicians
were able to accurately recognize the
thick-flat biotype in more than 70% of
the cases but were unable to identify
almost 50% of the thin-scalloped
cases. 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 and
calls for the need of additional infor-
mation before assessment such as the
actual thickness of the tissues.
49
Historically, 2 different biotypes
were identified, the thin and the thick.
Discrimination between thin and thick
biotype is somewhat difficult because
most patients do not fall into either ex-
tremes. In fact, a combination of both
biotypes may be found frequently
within the same patient. It was not until
recently that some authors reported a
medium biotype, with characteristics
between thin and thick biotypes.
49,71
In
fact, 80% of the sites cannot be clas-
sified as neither thin nor thick according
to the above-mentioned historical defi-
nition, evidencing the deficiency of the
classification.
69
Even though no signifi-
cant differences were found between
medium and thick biotypes in the study
by Linkevicius et al,
49
crestal bone loss
was still decreasing as tissue thickness
increases.
Upon this lack of agreement, a
consensus should be established to de-
fine thin, medium and thick biotypes.
Future studies should be directed to
address the primary question of a crit-
ical tissue thickness around implants
that promotes better surgical and pros-
thetic outcomes.
CONCLUSION
Periimplant tissue biotype is an in-
trinsic parameter that affects both the
esthetic and functional aspects of im-
plant rehabilitation by influencing the
remodeling of hard and soft tissues. Be-
cause thick biotype is a desirable fea-
ture, conversion of the patients mucosal
phenotype both quantitatively and qual-
itatively through soft tissue grafting pro-
vides more predictable surgical and
prosthetic outcomes. Based on the clin-
ical significance of periimplant tissue
thickness, measurement of this parame-
ter should be incorporated in the implan-
tologists routine evaluation to develop
a more comprehensive treatment plan.
Various tissue biotypes have different
physiological and pathological behav-
iors; therefore, treatment approach
should be tailored to each biotype to
enhance predictability of treatment
outcomes.
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 accurate
method of measurement is still not
agreed upon. A consensus should be
reached in regard to biotype classifi-
cation and the use of a method that can
serve 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 information
listed in the article.
ACKNOWLEDGMENTS
This article was partially sup-
ported by the University of Michigan
Periodontal Graduate Student Re-
search Funds.
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Abstract Translations
GERMAN / DEUTSCH
AUTOR(EN): Angie Lee, DMD, MS, Jia-Hui Fu, BDS,
Hom-Lay Wang, DDS, MSD, PhD
Biotyp des Weichgewebes beeinflusst den Implantierungserfolg
ZUSAMMENFASSUNG: Der Einfluss des Biotyps des
Gewebes bei der naturlichen Zahnstruktur ist bereits in der
Fachliteratur gut dokumentiert. Dabei weisen viele Dokumente
aus, dass dickeres Gewebe fur optimale chirurgische und pro-
thetische Ergebnisse bevorzugt wird. Diesem Gedankengang
folgend, zielen aktuelle Studien darauf ab herauszufinden, in-
wieweit die Dicke der Mukosa ahnliche Auswirkungen in den
Bereichen rund um Zahnimplantate herum hat. Dieser Bericht
zielte darauf ab, die Auswirkungen des Weichgewebsbiotyps in
Bezug auf den Erfolg einer Implantierungstherapie zu unter-
suchen. Der Einfluss des Gewebsbiotyps wurde in die nachfol-
genden drei Hauptkategorien unterteilt: dessen Beziehung zur
das Implantat umgebenden Mukosa und zum darunter liegenden
Knochengewebe, sofortiges Implantieren und die Wiederherstel-
lungsergebnisse. Der Biotyp des Weichgewebes ist ein wichtiger
Parameter, der bei der Erzielung eines asthetischen Implantier-
ungsergebnisses zu berucksichtigen ist. Es wird der unmittelbare
Implantierungserfolg verbessert und ein zukunftiges Zuruck-
weichen der Mukosa verhindert.
SCHLU

SSELWO

RTER: Gewebsbiotyp, Gewebsdicke, Zahnim-

plantat, Dicke der Mukosa, Weichgewebe, Implantierungserfolg
SPANISH / ESPAOL
AUTOR(ES): Angie Lee, DMD, MS, Jia-Hui Fu, BDS,
Hom-Lay Wang, DDS, MSD, PhD
El tipo biologico del tejido suave afecta el exito del implante
ABSTRACTO: La influencia del tipo biologico de tejido en
la denticion natural ya ha sido bien demostrada en las pub-
licaciones, con numerosos trabajos demostrando que el tejido
mas grueso es el tipo biologico preferido para obtener resul-
tados quirurgicos y prosteticos optimos. Siguiendo esa lnea
de pensamiento, los estudios actuales exploran si el espesor
de la mucosa tiene consecuencias similares alrededor de
implantes dentales. El proposito de esta evaluacion fue in-
vestigar los efectos del tipo biologico del tejido suave con
respecto al exito de la terapia de implante. La influencia del
tipo biologico de tejido se dividio en tres categoras princi-
pales: su relacion con la mucosa periimplante y el hueso
subyacente, la colocacion inmediata del implante y los resul-
tados de la restauracion. El tipo biologico del tejido suave es
un parametro importante que considerar para lograr una res-
tauracion estetica del implante, mejorar el exito inmediato del
implante y para prevenir la recesion futura de la mucosa.
PALABRAS CLAVES: tipo biologico de tejido, espesor del
tejido, implante dental, espesor de la mucosa, tejido suave,
exito del implante
PORTUGUESE / PORTUGUS
AUTOR(ES): Angie Lee, Doutor em Medicina Dentaria, Mestre
em Ciencia, Jia-Hui Fu, Bacharel em Cirurgia Dentaria, Hom-Lay
Wang, Cirurgiao-Dentista, Mestre em Odontologia, PhD
Biotipo do Tecido Mole Afeta Sucesso do Implante
RESUMO: A influencia do biotipo do tecido na denticao
natural ja esta bem demonstrada na literatura, com inumeros
artigos mostrando que o tecido mais espesso e um biotipo
preferido para resultados cirurgicos e proteticos otimos.
Nessa mesma linha de pensamento, os estudos atuais estao
voltados para explorar se a espessura mucosal teria implica-
IMPLANT DENTISTRY / VOLUME 20, NUMBER 3 2011 e45
coes semelhantes em torno de implantes dentarios. O objetivo
desta revisao era investigar os efeitos do biotipo do tecido
mole em relacao ao sucesso da terapia de implante. A in-
fluencia do biotipo do tecido foi dividida em tres categorias
principais: sua relacao com a mucosa do peri-implante e o
osso subjacente, colocacao imediata de implante e resultados
restauradores. O biotipo do tecido mole e um parametro
importante a considerar ao realizar a restauracao estetica do
implante, 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, sucesso
do implante
RUSSIAN /
ABTPM: Angie Lee, 1p 1xa1nn, xan1p
e1e1nennix na, Jia-Hui Fu, aaanp
xnppnnen 1xa1nn, Hom-Lay Wang, 1p
xnppnnen 1xa1nn, xan1p e1e1nennix
na n a1n 1xa1nn, 1p nnn
Bunnue umunu nux mune nu nex
ununmuuu
PE3RME. Bnxnne n1nna 1ann na 1nennie
:i e i xpm npnn1pnpnan n
n1epa1pe. B xnnnennix 1a1ixx i
na:an, n1 ee 11ax 1ani xnxe1x
npenn1n1einix n1nnx x nnennx
n1nxainix pe:i1a1n n xnppnn n
np1e:npnannn. Hpax annn xii, n
na1xmee npexx nenannx nanpaneni na 1,
n1i nixnn1i, e1 n 1mnna n:n1n
xnix pa:x nnx1i na :nie nxnan1a1i.
Hei ann :pa nena1i nnxnne n1nna
xxnx 1anen na pe:i1a1nnn1i enennx npn
nxnan1annn. Xapa1ep nnxnnx n1nna 1ann i
1neen 1pex nnnix a1epnxx: nx:annin
nepnnxnan1a1nn n:n1n nn n
neamen 1in, nexeennn 1annn
nxnan1a1a n pe:i1a1axn np1e:npnannx.
n1nn xxnx 1anen xnxe1x nanix napaxe1px,
1pin ee1 nn1ina1i npn enenennn
:1e1nnnn pe1anpannn nxnan1a1a, nnimennn
pe:i1a1nnn1n nexeennn 1annn
nxnan1a1a n npe1npamennn penenn n:n1n
nn n mex.
RHEBME BA: n1nn 1ann, 1mnna
1ann, :nn nxnan1a1, 1mnna n:n1n
nn, xxax 1ani, pe:i1a1nnn1i 1annn
nxnan1a1a
TURKISH / TU

RKC E
YAZARLAR: Angie Lee, DMD, MS, Jia-Hui Fu, BDS, Hom-
Lay Wang, DDS, MSD, PhD
Yumusak Dokunun Biyotipi I

mplant Basarsn Etkiler

O

ZET: Dogal dislerde doku biyotipinin etkisi literaturde

kantlanms ve saysz yaz, kaln dokunun cerrahide ve pro-
tezde en iyi sonuclar alma acsndan tercih edilen biyotip
oldugunu belirtmistir. Ayn dusunceden yola ckan
halihazrdaki calsmalar, mukozal kalnlgn dental implantlar
uzerinde benzer etkilerinin olup olmadgn arastrmaktadr.
Bu calsmann amac, yumusak doku biyotipinin implant tera-
pisinin basars uzerine etkisini degerlendirmekti. Doku biy-
otipinin etkisi uc ana kategoriye ayrld: peri-implant
mukozas ve altta yatan kemik ile baglants, hemen implant
yukleme ile baglants ve restoratif sonuclar ile ilintisi.
Yumusak doku biyotipi, estetik implant restorasyonu
saglamak, hemen implant yukleme basarsn arttrmak ve
ileride mukozann geri cekilmesini onlemek icin goz onune
alnacak onemli bir parametredir.
ANAHTAR KELI

MELER: doku biyotipi, doku kalnlg,

dental implant, mukoza kalnlg, yumusak doku, implant
basars
e46 SOFT TISSUE BIOTYPE AFFECTS IMPLANT SUCCESS LEE ET AL
JAPANESE /
CHINESE /
KOREAN /
IMPLANT DENTISTRY / VOLUME 20, NUMBER 3 2011 e47