Mucogingival approach for combined implant placement, soft-tissue augmentation, and periodontal regeneration: 6-year outcomes

Problems of Dental Medicine 51 DOI: 10.3897/pdm.51.e172977 Methods Copyright by Hristina Maynalovska et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1 Mucogingival approach for combined implant placement, soft-tissue augmentation, and periodontal regeneration: 6year outcomes Kamen Kotsilkov, Zdravka Pashova-Tasseva, Hristina Maynalovska 1 Department of Periodontology, Faculty of Dental Medicine, Medical University – Sofia, Bulgaria Corresponding author: Hristina Maynalovska, Sofia, Bulgaria; Email: [email protected] Received: 23 September 2025  Accepted: 6 November 2025  Published: 17 November 2025 Citation: Kotsilkov K, Pashova-Tasseva Z., Maynalovska H (2025) Mucogingival approach for combined implant placement, soft-tissue augmentation, and periodontal regeneration: 6-year outcomes. Problems of Dental Medicine 51. 1-5. doi: 10.3897/pdm.51.e172977. Abstract Long-term implant success depends on prosthetically driven three-dimensional positioning and the stability of peri-implant and adjacent periodontal tissues. In partially edentulous patients—especially those with a history of periodontitis—an untreated vertical intrabony defect next to the planned implant site can impair plaque control and jeopardize peri-implant hard-tissue stability. This case report presents a 54-year-old, systemically healthy patient with a history of periodontitis, missing the mandibular right first molar (46) and exhibiting a combined mesial intrabony defect at the adjacent second molar (47). Management combined implant placement at site 46 with minimally invasive regenerative surgery at 47 and soft-tissue phenotype modification using a connective tissue graft. Healing was uneventful, and 6-year follow-up demonstrated stable crestal bone at the implant, sustained radiographic fill of the mesial defect, and favorable, well-contoured peri-implant soft tissues. Results: The results suggest that simultaneous guided implant placement with adjacent defect regeneration and connective tissue grafting may achieve durable hardand soft-tissue stability over years. Keywords dental implants, periodontal regeneration, soft-tissue augmentation, vertical bone defects Introduction Patients with a history of periodontitis commonly receive implant therapy. Tooth loss is a frequent sequela of periodontitis, and implant-supported restorations provide a predictable means of rehabilitating function and occlusion (1,2). Nevertheless, a history of periodontitis and residual periodontal infection are recognized risk factors for biological complications (e.g., peri-implantitis) and implant failure (3,4). Accordingly, implant therapy in periodontally susceptible patients should be undertaken following infection control and with careful attention to the peri-implant soft-tissue phenotype, which supports hygiene and mucosal stability (5,6). Soft-tissue augmentation is routinely used at implant sites to manage esthetic issues, increase mucosal thickness, widen the band of keratinized mucosa, and reconstruct papillae (7,8). An adequate width of Hristina Maynalovska et al. 2 Problems of Dental Medicine I 2025 I Vol. 51 keratinized mucosa is associated with improved brushing comfort and maintenance of peri-implant health; clinically, a width of ≥2 mm is commonly targeted (9,10). Mucosal thickness also matters: thicker tissues enhance color match and are associated with more stable marginal bone levels. Increasing soft-tissue thickness can help maintain the peri-implant mucosal margin over time (11–13). Accordingly, implant therapy should be planned to secure both adequate keratinized mucosa width and soft-tissue thickness, especially in periodontitis-susceptible patients. Vertical (angular) intrabony defects develop as periodontitis migrates apically, leaving the pocket base positioned apical to the alveolar crest and bounded by residual osseous walls. Because their complex, irregular morphology limits access for effective subgingival biofilm control, these lesions often persist after initial causerelated therapy (14). If not addressed, they are associated with ongoing disease activity and a higher risk of tooth loss (15). Accordingly, adjunctive surgical management is frequently indicated, in addition to etiologic therapy, to prevent further breakdown of the periodontal supporting tissues (14). The long-term success of implant therapy depends not only on accurate, prosthetically driven placement but also on effective control of periodontal disease and optimization of the peri-implant soft-tissue phenotype. When a vertical intrabony defect is adjacent to a partially edentulous site, failure to treat it can impair plaque control and jeopardize peri-implant hard-tissue stability around the planned implant. Where ridge volume is adequate, a combined approach—guided implant placement with concurrent periodontal regeneration and soft-tissue augmentation—can shorten treatment time and preserve tissue architecture. This case report presents simultaneous placement of a mandibular implant at site 46 with regeneration of a combined mesial intrabony defect at tooth 47 and concomitant soft-tissue augmentation, with clinical and radiographic outcomes documented through 6 years. Materials and methods Methods Case presentation A 54-year-old, systemically healthy, nonsmoking man with no regular medications and no known drug allergies presented with Stage III, Grade B periodontitis (2018 classification (16)) and a missing mandibular right first molar (tooth 46). Following initial nonsurgical periodontal therapy using a minimally invasive protocol (17,18) , the two-month re-evaluation revealed a residual periodontal pocket on the mesial aspect of the mandibular right second molar (tooth 47), with probing depths of 8 mm at the mesiobuccal and 14 mm at the mesiolingual sites (Figure 1). Tooth 47 was stable, with no furcation involvement. Figure 1. Clinical status at 2 months reevaluation Cone-beam computed tomography (CBCT) confirmed a combined vertical intrabony defect on the mesial aspect of tooth 47, with an intraosseous component measuring 9 mm in depth (5 mm one-wall component, 2 mm two-wall component (lingual wall was more preserved) and 2mm three-wall component). The supracrestal defect component measured 3 mm, and the supracrestal softtissue height was 6 mm. The radiographic defect angle, defined as the angle between the root surface and the residual bony wall, was 33°. No furcation involvement was evident on CBCT, consistent with the clinical findings (Figure 2). Figure 2. Presurgical CBCT evaluation The treatment plan comprised a mucogingival single (buccal) flap approach with implant placement at site 46, simultaneous regenerative treatment of the mesial intrabony defect at tooth 47, and soft-tissue augmentation using a connective tissue graft. Under local anesthesia, a subcrestal incision was made at the buccal aspect of the alveolar crest from the mesiobuccal line angle of tooth 47 to the distobuccal line angle of tooth 45, providing access to the mesial defect at 47 and the edentulous site 46. In accordance with minimally invasive principles, a split thickness flap was raised to the buccal bone crest, followed by elevation of a limited full-thickness mucoperiosteal flap to expose 2 mm of the marginal bone bordering the vertical defect. Flap elevation was continued with a deep split-thickness incision separating the mucosa and the muscle layer from the periosteum, followed by a superficial split-thickness dissection separating the mucosa from the underlying muscles, to achieve controlled flap mobility while preserving soft-tissue thickness. At the site of the vertical bony defect, a horizontal incision was made at the level of the bone crest to separate the supracrestal soft tissues from those occupying the intrabony component. Thorough degranulation and defect debridement were performed, and the mesial root surface of tooth 47 was meticulously instrumented with mechanical and hand instruments. The root surface was conditioned with 24% EDTA gel for 2 minutes, after which the site was irrigated copiously with sterile saline. Enamel matrix derivates were then applied, beginning at the base of the defect and extending to cover the entire exposed root surface. The crestal part of the Case report - implant placement, augmentation, and regeneration Problems of Dental Medicine I 2025 I Vol. 51 3 mucosa was de-epithelialized to the level of the maximal coronal extension of the buccal flap (Figure 3). Figure 3. Stepwise workflow for tooth 47. A. Limited fullthickness flap elevation; B. Split-thickness dissection to gain flap mobility; C. Horizontal incision at the vertical defect separating supracrestal from intrabony soft tissues; D. Thorough degranulation and debridement of the intrabony defect; E. Defect after debridement; F. Application of EDTA gel for root conditioning; G. Application of enamel matrix derivative; H. Deepithelialization of the crestal part of the mucosa. Using a prefabricated, tooth-supported surgical guide, the planned implant position at site 46 was verified and marked intraoperatively. A narrow crestal mucosal strip directly over the planned abutment emergence was excised, removing the portion of the crestal mucosa covering the implant site. With the crest exposed, a guided osteotomy was prepared at site 46, followed by osseodensification using Verasah® burs to expand the osteotomy in a controlled manner – preferentially distally - to reduce the width of the adjacent intraosseous periodontal defect. A TSV 4,5/10 ZimVie Inc. dental implant was then inserted with adequate primary stability (>40N/cm). A concave healing abutment was then connected to support peri-implant soft-tissue shaping. (Figure 4). Figure 4. Stepwise workflow at site 46. A. Verification of the planned implant position using the surgical guide; B. Crestal mucosal strip excision; C. Guided osteotomy—pilot drill; D. Osteotomy—final drill; E. Implant placement; F. Placement of a concave healing abutment. After implant placement at site 46, a connective tissue graft (CTG) was harvested from a posterior palatal donor site and de-epithelialized extraorally. The intrabony defect on the mesial aspect of tooth 47 was filled with bone graft material. The CTG was then adapted to cover the coronal entrance of the defect, extending anteriorly toward tooth 45 and was stabilized with simple interrupted sutures to the de-epithelized crestal mucosa (PGA 7/0, 7 mm needle). In this case, the CTG stabilized the blood clot within the intrabony defect and augmented the peri-implant soft tissues, thereby promoting an adequate soft-tissue seal around the implant. The buccal flap was coronally advanced and secured around the placed healing abutment using a O-type sutures (PGA 6/0, 12 mm needle). A postsurgical radiograph was also taken (Figure 5). Figure 5. End-of-procedure workflow. A. Bone graft placement; B. CTG positioning; C. Coronally advanced flap suturing; D. Postoperative periapical radiograph. Healing was uneventful. At 2 weeks postoperatively, edema had resolved and the wound margins were intact, with a thick, well-contoured band of keratinized mucosa surrounding the healing abutment. At 3 months the softtissue profile remained stable with sufficient volume to support the definitive prosthetic restoration (Figure 6). Figure 6. Soft-tissue healing. A. At 2 weeks; B. At 3 months. The monitoring of the development of the soft-tissue profile after placement of the prosthetic constructions demonstrated a gradual increase in the volume of the periimplant soft tissues under the influence of the created adequate emergence profile of the restorations (Figures 7 and 8). Hristina Maynalovska et al. 4 Problems of Dental Medicine I 2025 I Vol. 51 Figure 7. Occlusal views of prosthetic-guided soft-tissue profile development. A. 3 months; B. 4 months (at provisional crown placement); C. 8 months (with definitive crown); D. 12 months (4 months after the definitive crown). Figure 8. Lateral views of prosthetically guided soft-tissue profile development. A. 4 months, provisional crown placement; B. 8 months, definitive crown placement; C. 6 years, definitive crown in situ. Peri-implant mucosal levels remained stable through the 6-year recall, with a harmonious emergence profile and complete papillary fill adjacent to the implant The soft tissue profile matured to establish an adequate soft tissue seal and the probing depth at the site of the regenerative surgery was 4mm (Figure 9.) Figure 9. Six-year clinical follow-up. The periapical radiographs at 6 months, 12 months, and 6 years show preservation of crestal bone at the implant platform, with unchanged mesial and distal marginal levels and no peri-implant radiolucency. The mesial vertical intrabony defect at tooth 47 demonstrates progressive radiographic bone fill with re-establishment of a continuous lamina dura and maturation of the trabecular pattern by 12 months, which is maintained at 6 years. Collectively, these findings indicate long-term peri-implant hard-tissue stability and a durable regenerative outcome at the adjacent site (Figure 10). Figure 10. Longitudinal radiographic follow-up. A. 6 months; B. 12 months; C. 6 years. Discussion This case illustrates a coordinated approach in a patient with a history of periodontitis, integrating guided implant placement at site 46 with regeneration of a combined mesial intrabony defect at tooth 47 and concomitant softtissue augmentation at the implant site. The protocol delivered uneventful healing, a stable peri-implant mucosal margin, and long-term maintenance of crestal bone levels at the implant, together with progressive radiographic fill of the adjacent vertical defect that remained stable through 6 years. Simultaneous management offers practical advantages: fewer interventions, greater patient comfort and costeffectiveness, and an earlier return to function. However, it requires meticulous infection control, excellent patient compliance, precise case planning with robust risk management, and an experienced clinician. In this case, flap release via a mucogingival approach, combined with a minimally invasive regenerative protocol for the vertical intrabony defect, facilitated controlled flap mobility and optimized space maintenance (19,20). The concomitant use of a connective tissue graft (CTG) served both to augment the peri-implant soft tissues and to seal the coronal aspect of the periodontal defect, thereby enhancing clot stability and protecting the grafted site (21). Although one-wall and two-wall components of the intrabony defects are generally less favorable than threewall components, the described protocol likely contributed to the observed radiographic bone fill (22). Building on these measures, soft-tissue phenotype optimization was integrated throughout the workflow. The CTG thickened the peri-implant and adjacent mucosa, supporting plaque control and long-term mucosal stability—critical considerations in patients with a periodontal history. Within the limitations of a single case report, this case demonstrates the feasibility of a simultaneous, tissuepreserving approach integrating guided implant placement with biologically driven periodontal regeneration and soft-tissue phenotype modification. Stable hardand soft-tissue outcomes were maintained over 6 years Case report - implant placement, augmentation, and regeneration Problems of Dental Medicine I 2025 I Vol. 51 5 Conclusion The simultaneous, prosthetically driven guided implant placement at site 46 combined with regenerative management of the adjacent mesial intrabony defect at tooth 47 - including EDTA conditioning with enamel matrix derivative, bone grafting, and soft-tissue augmentation with a de-epithelialized palatal CTG - resulted in uneventful healing, stable crestal bone levels at the implant platform, and progressive radiographic fill of the vertical defect that was maintained through 6 years. Clinically, a thick, well-contoured band of keratinized mucosa, stable mucosal margins, and a harmonious emergence profile were observed. This coordinated, tissue-preserving approach may be considered when ridge volume is adequate and infection control has been achieved in periodontitis-susceptible patients. Careful case selection, meticulous flap and closure management, and prosthetically driven planning appear critical. Additional information Funding statement The authors have no funding to report. Ethical compliance Not applicable. Conflict of interest The authors declare that they have no conflict of interest and no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript. References 1. 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