Modified Vascularized Interpostional Periosteal Connective Tissue Graft Versus Xenogeneic Collagen Matrix for Soft Tissue Augmentation Around Implant in Esthetic Zone (Comparative Study)
Phase: NA
Conditions: Dental, Implant
Sponsor: Minia University

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Modified Vascularized Interpositional 
Periosteal Connective Tissue Graft Versus 
Xenogeneic Collagen Matrix For soft tissue 
Augmentation Around Implant in Esthetic 
Zone 
(A Comparative Study)  
 
Proposal 
 
Presented By 
 
Heba Ahmed Abd El-Maged Elsweefy 
 
  
21/11/ 2021 
 
 
 
 
 
 
 
 
 

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Introduction and Review  
 
 
Immediate implant placement defined as the positioning of a dental implant 
immediately into fresh extraction socket after tooth extraction, it's a predictable and 
acceptable procedure for redressing missing teeth (Mazzotti, Stefanini et al. 2018). 
The immediate implant placement in anterior maxilla represent one of the most 
challenging areas and require orchestrated steps and protocols to help achieving 
predictable and long term esthetic outcomes (Dixon and Yassin 2020). 
Contrary to popular belief, it is now evident that labial bone contour cannot be 
maintained by placing implants in fresh extraction sockets. Dimensional changes, 
including the loss of labial soft tissues and mid buccal mucosal recessions, seem to be 
inevitable following immediate placement. Even when guided bone regeneration is 
simultaneously performed to correct peri-implant bone defects or to fill horizontal gaps 
between implants and socket walls, changes in soft tissue levels may still occur, 
particularly in the presence of thin gingival biotypes or inadequate width of keratinized 
tissues(Atieh and Alsabeeha 2020). 
Peri-implant soft tissue has attracted great attention recently as it is hypothesized 
that a sufficient amount of keratinized mucosa may establish a stable epithelial seal 
around dental implants, which is beneficial for avoiding bacterial penetration (Huang, 
Liu et al. 2021). 
Hence, thickening the soft tissue and increasing the amount of keratinized mucosa 
with autogenous soft tissue grafts (Chung, Rungcharassaeng et al. 2011) or tissue 
substitutes (Sanz, Lorenzo et al. 2009) were thought to reduce the risk of mucosal 
recession, maintain the stability of peri-implant mucosal level and compensate for peri-
implant mucosal changes following immediate implant placement and restoration(IIPR) 
(Atieh and Alsabeeha 2020). 

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Most techniques of soft tissue augmentation procedure have the drawback of less 
gain in volume because of limited size of the graft that can be used. Large onlay grafts 
have chances of necrosis due to lack of sufficient blood supply (Cheng 2016) . 
In 2003, Sclar in his book, "Soft Tissue and Esthetic Consideration in Implant 
Therapy" described a pedicle CT grafting technique namely VIP‑CT flap. It was 
introduced as anteriorly based pediculated tissue of palatal submucosa that composed 
of periosteum and connective tissue. It is preferred for large volume soft tissue 
augmentation and for simultaneous hard and soft tissue grafting (Sclar 2003).  
The procedure involves raising a subepithelial palatal connective tissue periosteal 
flap and rotating it into the prepared anterior recipient site. It is then positioned beneath 
the curvilinear recipient flap and rigidly immobilized with sutures(Landi and 
Sabatucci 2001). The main advantages of this technique are the amount of tissue gain 
is more and the pedicled blood supply is derived from the connective tissue periosteal 
plexus within the flap that provides the biological basis for predictable coverage 
(Rahpeyma, khajeh Ahmadi et al. 2012). 
Kim proposed a modified VIP‑CT (mVIP-CT) graft in the implant site including 
papilla preservation flap in the implant site in order to minimizes tissue insult thus 
reduces postoperative shrinkage, maintains the intact vascularity of donor site even 
better and achieving optimum results with negligible tissue trauma (Kim, Jang et al. 
2012). 
This modification of VIP‑CT flap differs from the conventional technique by 
lacking the releasing incisions at donor site for advancing the pedicle over the recipient 
site. Instead in this proposed technique, the advancing was done through tunneling 
procedure. An anteroposterior subperiosteal tunneling was done on the palate near 
implant site to create a passageway for pedicle graft connecting donor and recipient sites 
(Kumar, Gayatri et al. 2015). 

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A new soft tissue substitute xenogenic collagen matrix (XCM) is a xenogenic-
derived absorbable bio-membrane, commonly used as three-dimensional matrix is 
composed of two layers: a compact layer, which is beneficial to suturing and wound 
protection, and a porous layer that favours blood clot stabilization, rapid vascularization, 
and tissue integration(Huang, Liu et al. 2021). 
This novel tridimensional xenogenic derived acellular dermal matrix, derived 
from the porcine dermis composed of natural types I and III collagen without any 
artificial cross-linking, has been developed for multiple clinical situations (Papi and 
Pompa 2018). 
Previous studies have investigated the clinical efficacy of XCM for augmenting 
keratinized mucosa and reported promising results (Schmitt, Moest et al. 2016). 
So, our research aiming to compare between modified VIP-CT graft and 
xenogenic collagen matrix membrane for soft tissue augmentation around dental 
implant in esthetic zone. 
 
 
 
 
 
 
 
 
 
 

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Aim of the study 
 
-The primary aim of this study is to evaluate the efficacy of mVIP-CT graft technique 
for soft tissue augmentation around dental implant in esthetic zone. 
-The secondary aim is to compare between mVIP-CT graft and xenogenic collagen 
matrix membrane for soft tissue augmentation around dental implant in esthetic zone. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Patients and methods 
 
 
Patient selection 
This study will be conducted on 20 patients with missing maxillary teeth in esthetic zone 
seeking its replacement. After approval from the ethical committee, patients will select 
from the outpatient clinic, Department of Oral medicine, Diagnosis and Periodontology, 
Faculty of Dentistry, Minia University. 
Inclusion criteria 
1. Selected patients of both sexes are 20-40 years old.  
2. Patients are systemically healthy based on questionnaire dental modification of 
Cornell index. 
3. Good oral health 
4. The recipient site of the implant is free from any pathological conditions. 
5. Necessity for soft tissue volume augmentation at the buccal implant site (thin 
gingival biotype with a narrower zone of keratinized tissue & decrease in 
papilla height)  
6. Adequate interocclusal space to accommodate the available restorative 
components.  
7. Adequate native/apical bone to achieve primary implant stability.  
 
Exclusion criteria: 
1. Pregnant female 
2. Parafunctional habits such as bruxism and clenching Patients suffering from 
periodontitis. 
3. Untreated periodontitis and poor oral  hygiene   
4.  Patients underwent any prior periodontal surgery in the relevant region for at 
least 6 months prior to this study 
5. Smokers. 
 

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Ethical regulation 
     All patients will undergo an immediate implant placement and the complete 
treatment plan will be explained to all patients including detailed steps, risks, and 
expected results. Verbal and written informed consent will obtained from all patients 
before the commencement of the study. All experiments will be examined and approved 
by the appropriate ethics committee and have therefore been performed in accordance 
with the ethical standards laid down in the 1964 Declaration of Helsinki and the research 
ethics committee of the Faculty of Dentistry, Minia University. 
 
Pre surgical phase 
1. All selected patients will be screened by comprehensive periodontal examination 
and full periodontal charts will be obtained. A preoperative cone beam computed 
tomography (CBCT) will be performed for each patient who met the inclusion 
criteria prior to the surgery to determine bone height and width and decide the 
implant length and diameter to be placed and to evaluate the underlying bone 
condition. 
2. Trans-gingival probing will be done at the mesial line angle 2, 4 and 6 mm apical 
to the gingival margin. At the same apico-coronal direction three points will be 
recorded at the mid-buccal and at the distal line angle (Rotenberg and Tatakis 
2014) 
3. The width of keratinized gingiva will be measured using UNC-15 probe and 
recorded as the distance from the mucogingival junction to the gingival margin. 
 
 
 
 
Randomization 
      The study will use simple randomization to allocate patients into 2 groups, each 
group will be included 10 patients. 
Then, random allocation will be performed using computer-generated random numbers 
to determine which group they will be assigned. 
 
• Group 1: Immediate dental implant +Xenogenic bone graft +mVIP-CT graft 
technique  

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• Group 2: Immediate dental implant + Xenogenic bone graft+ Xenogenic collagen 
matrix membrane 
Surgical Phase 
In group 1" the mVIP-CT group " 
1. After obtaining adequate local anesthesia (2% lidocaine HCL 1:100000 
epinephrine), atraumatic extraction using periotome will done followed by 
immediate implant placement.  
2. After ensuring the correct three‑dimensional placement of the implant, the 
jumping distance between the implant and socket will grafted with xenogeic bone 
graft. 
3. Soft tissue augmentation will be planned over the implant site. Modified VIP‑CT 
graft will be harvested with modified single incision technique from the palate 
and the advancement will done through palatal tunneling procedure. 
4. An anteroposterior subperiosteal tunneling will done on the palate near implant 
site to create a passageway for pedicle graft connecting donor and recipient sites.  
5. The posterior end of the tunnel prepared mesial to the single incision on the 
palate. The passageway of the tunnel prepared will further checked using an 
instrument.  
6. Then the flap advanced over the jumping distance through the tunnel into the 
implant site. The pedicle graft will stabilized using external mattress sutures and 
the donor site by cross‑mattress sutures with 6–0 vicryl suture.  
 
In group 2 " XCM group " 
1. After obtaining adequate local anesthesia (2%lidocaine HCL 1:100000 
epinephrine), atraumatic extraction using periotome will done followed by 
immediate implant placement.  
2. After ensuring the correct three‑dimensional placement of the implant, the 
jumping distance between the implant and socket will grafted with xenogeic bone 
graft. 

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3. The matrix will be rehydrated with sterile saline solution and then trimmed with 
scissors to fit into the buccal pouch. The matrix, used in one layer with a thickness 
ranging from 1.2 to 1.7 mm (prior rehydrating).  
4. The crestal aspect of the split-thickness flap and the underlying CM will be 
sutured to the palatal flap with interrupted sutures (resorbable, Vicryl 6.0 suture) 
at the mesial and distal aspects. 
 
Postoperative instructions  
1. Routine verbal and written postoperative instructions for periodontal surgery will 
be given to all patients including ice compression on the surgical site during the 
first 4 h, a liquid and/or soft food diet for 3 days. 
2. As with all surgical procedures, patients will be informed to contact the therapist if 
any problems will be developed during postoperative period. 
3. The postoperative medications prescribed will be (Amoxicillin+ clavulenic 
acid*625mg for 8 days) * every 8 h or clindamycin 300 g every 8 h for 7 days for 
patients allergic to penicillin, and (Ibuprofen**600 mg every 12 h for 5 days).  
4. The patients will be advised to refrain from retracting the lips and cheeks and to 
avoid brushing or flossing in the grafted area for 6 weeks.  
5. The sutures remained in situ for 2 weeks.  
 
Clinical assessment: 
All patients included in the present study will followed carefully and monitored to 
motivate the patient for oral hygiene instructions and for maintenance of good oral 
hygiene. 
 
 
 
*( Amoxicillin +clavulenic acid) , GlaxoSmithKline, Egypt. 
 ** Brufen ®, Abbott, Egyp 

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All patients will be examined at baseline (immediately after the implant insertion), 3 
and 6 months for the following criteria to evaluate esthetic results around dental 
implants, include: 
 
1. Gingival thickness (GT) 
2. keratinized tissue width (KTW) 
3. Pink esthetic score (PES) to evaluate the soft tissue surrounding the crown. 
4. Buccal bone thickness 
 
Statistical analysis: 
-All data will be tabulated and analyzed by statistical method.