Clinical context and challenges of peri-implant tissue thickness

In the aesthetic zone of the anterior maxilla, the thickness of peri-implant soft tissues is a determining factor for long-term prosthetic stability and aesthetic integration. The practitioner is frequently faced with thin gingival biotypes where the lack of tissue volume compromises the emergence profile and the durability of the result. To overcome this insufficiency, autogenous connective tissue graft techniques remain the gold standard, but they systematically require the creation of a second donor site, thus increasing postoperative morbidity and surgical time.

Objective and approach of the case study

This case report documents a surgical alternative aimed at increasing gingival volume without palatal harvesting in a 28-year-old patient presenting with a missing maxillary central incisor associated with a thin biotype. The objective is to evaluate the efficacy of a modified "split flap–roll" technique performed during implant placement. The approach is based on the dissociation of the flap into two components (epithelial and connective), with the connective tissue then being mobilized and rolled as a pedicle into a vestibular pocket. The hypothesis tested is that this technical modification allows for a significant and stable increase in tissue thickness, while optimizing the gingival contour and emergence profile without recourse to a secondary donor site.

Clinical methodology: split-thickness roll flap protocol

This case report documents the surgical management of a 28-year-old systemically healthy male patient presenting with an edentulous maxillary central incisor. The clinical site was characterized by a thin gingival biotype, with an initial soft tissue thickness measured at less than 2 mm.

The surgical protocol implemented a modified split flap–roll technique according to the following steps:

• Implant placement: Procedure performed in the maxillary aesthetic zone.
• Flap preparation: Surgical flap splitting to distinctly separate the epithelial component from the connective component.
• Mobilization and rolling: The connective component, preserved as a pedicle to maintain its vascularization, was mobilized and then rolled inside a labial vestibular pocket.
• Technical objective: This pedicled approach aims for local volumetric augmentation without resorting to a secondary donor site (palatal harvest).

The analysis of the results was based on longitudinal clinical follow-up. Soft tissue thickness was evaluated at three key stages: preoperatively, at 3 months, and at 9 months post-intervention. Evaluation criteria also included the quality of healing, the evolution of the gingival contour, and the prosthetic emergence profile.

Clinical results and evolution of tissue thickness

The clinical follow-up of this 28-year-old patient demonstrated a significant volumetric increase of the peri-implant soft tissues at the level of the maxillary central incisor. Healing was uneventful over the entire 9-month follow-up period.

The quantitative evolution of soft tissue thickness, measured during the different phases of the protocol, is detailed in the following table:

From a qualitative perspective, clinical observations highlight several aesthetic and functional benefits:

• Gingival contour: A notable improvement in tissue contour was achieved through the rolling of the pediculated connective tissue into the labial pocket.
• Emergence profile: The flap design allowed for the creation of a harmonious prosthetic emergence profile.
• Stability: Although slight tissue maturation was observed between 3 and 9 months (decrease from 4 mm to 3 mm), the thickness remained stable and more than 50% greater than the initial biotype.

As this is a single case report (n=1), no comparative statistical analysis (p-value) was performed. However, the absence of a secondary donor site reduced intraoperative morbidity while achieving the targeted tissue augmentation goals for this thin biotype.

Analysis of results and clinical relevance

This case report highlights the effectiveness of a modified split flap–roll technique for peri-implant soft tissue augmentation. In this 28-year-old patient, the gingival thickness increased from less than 2 mm preoperatively to approximately 4 mm at 3 months, stabilizing at 3 mm after 9 months of follow-up. Clinically, this 50% gain compared to the initial situation optimized the emergence profile and gingival contour in a demanding aesthetic zone (maxillary central incisor), while ensuring complication-free healing.

The major interest lies in the pedicled nature of the connective tissue graft. Unlike conventional connective tissue grafts (CTG), this approach preserves proximal vascularization, which promotes the survival of the transposed tissue. Furthermore, the absence of a secondary donor site (usually palatal) drastically reduces postoperative morbidity and simplifies the patient's acceptance of the treatment plan.

Limits and technical considerations

The obvious weakness remains the level of evidence: this is a single case report (n=1). Although the 9-month results are encouraging, the very long-term tissue stability (beyond 2 years) remains to be demonstrated. Furthermore, this technique requires sufficient local tissue availability at the ridge level to allow for the connective tissue roll, which limits its application to cases where the initial volume of keratinized mucosa permits.

Conclusion

This technical modification offers a viable alternative to free grafts for thickening a thin biotype without increasing surgical trauma.

Summary of results

In a 28-year-old patient, the split-thickness roll flap technique allowed for an increase in soft tissue thickness from less than 2 mm to approximately 4 mm at 3 months, stabilizing at 3 mm at 9 months. This surgical modification provides an aesthetic emergence profile and uneventful healing without the need for a connective tissue graft harvested from the palate.

In concrete terms, for the practitioner:

• Avoid the secondary donor site: Use this pedicled approach to increase vestibular volume while reducing morbidity and surgical time.
• Anticipate tissue contraction: Aim for over-correction when creating the labial pocket, as results show a slight decrease in thickness (1 mm) between 3 and 9 months of follow-up.
• Target aesthetic zones: This technique is particularly indicated for the maxillary anterior sector in order to sculpt a natural gingival contour on an initially thin biotype.

Technical lexicon of the study

Thin gingival biotype: Gingival morphology characterized by reduced tissue thickness (less than 2 mm in this clinical case), presenting an increased risk of recession and implant transparency, which often requires compensatory augmentation.

Split flap: Surgical dissection technique consisting of separating the epithelial and connective components of the flap in order to specifically mobilize the connective tissue while preserving the integrity of the superficial layer.

Modified roll technique: Volumetric augmentation procedure where a portion of connective tissue is dissected, mobilized, and then rolled onto itself to be positioned in a deficient area to increase vestibular thickness.

Pedicled approach: Tissue transfer method where the graft remains attached to its original site by a vascular base, ensuring continuous blood supply and eliminating the need for harvesting from a secondary donor site.

Labial pouch: Surgical space created by submucosal dissection on the vestibular (labial) side to receive the rolled connective tissue, thus allowing the external gingival contour to be bulked.

Emergence profile: Axial contour of the prosthesis and surrounding soft tissues at the passage of the marginal gingiva, crucial for the aesthetics and biological integration of the implant restoration.

Secondary donor site: Tissue harvesting area (usually the palate) distinct from the implant site. Avoiding it in this technique reduces overall morbidity and simplifies postoperative recovery for the patient.

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