Soft t issue e nhancement a fter i mplant p lacement Christian F.J. Stappert MS, DDS, PhD, Priv. - Doz. and Davide Romeo DDS, PhD
Introduction
Replacement of missing teeth with endosseous implants is a predictable and reliable procedure, with high implant and prosthetic survival rates and stable long - term results (Esposito et al., 2009a,b ).
In recent years, the goal of implant treatment in the anterior zone has progressed from mere fi xture survival to obtaining a long - lasting esthetic result with stable peri - implant tissue conditions as well as harmony of implant - restorations with neighboring teeth (Meijer et al., 2005 ). Therefore, additional factors such as soft tissue appearance, restorative outcomes, and patient satisfaction have to be taken into consideration in evalu-ating the success of implant patient rehabilitation, espe-cially in the anterior esthetic zone.
The aim of this chapter is to give an overview of soft tissue healing and biology and to focus on different tech-niques to improve esthetic outcomes during second - stage surgery of dental implants.
Keratinized t issue a round d ental i mplants
For years one of the most controversial subjects regarded the amount of keratinized gingiva ( KG ) necessary to maintain the periodontal health around teeth. Lang and L ö e (1972) stated that a minimum of 2 mm of KG with at least 1 mm of attached gingiva should be present in order to prevent soft tissue recession, but clinical and experi-mental studies reported that healthy conditions could be
maintained almost with no attached gingiva (Dorfman et al., 1980, 1982 ; Hangorsky and Bissada, 1980 ; Kennedy et al., 1985 ; Miyasato et al., 1977 ; Wennstrom, 1983 ; Wennstrom and Lindhe, 1983 ; Wennstrom et al., 1981 ). However, due to the inductive potential of the periodon-tal ligament to determine the characteristics of periodon-tal mucosa, a width of 0.5 mm of KG is always present around healthy teeth (Karring et al., 1975 ). Wennstrom (1987) was not able to demonstrate differences in the progression of infl ammation in areas with limited kera-tinized tissue in an animal model, and human studies did not report signifi cant changes in the attachment level if plaque control is adequate (Dorfman et al., 1982 ; Freedman et al., 1999 ; Hangorsky and Bissada, 1980 ; Kennedy et al., 1985 ; Kisch et al., 1986 ; Lindhe and Nyman, 1980 ; Salkin et al., 1987 ; Schoo and van der Velden, 1985 ). In a study based on 32 patients with bilat-eral areas of minimal or no keratinized tissue, Kennedy performed a free gingival graft (FGG) on one side while the contralateral area was maintained as control. After 6 years, there was no statistical difference related to recession and clinical attachment loss between the two groups, if a proper oral hygienic protocol was main-tained (Kennedy et al., 1985 ).
Clinical experience, more than scientifi c evidence, sug-gests that thick gingiva may be more resistant and may reduce possible soft tissue recession in the presence of gingival infl ammation or brushing trauma. Many clinical studies (Arowojolu, 2000 ; Checchi et al., 1999 ; Khocht et al., 1993 ; Kozlowska et al., 2005 ; Sangnes and Gjermo, 1976 ; Tsami - Pandi and Komboli - Kontovazeniti, 1999 ; Vehkalahti, 1989 ) showed a direct relationship between brushing and noninfl ammatory recessions, even though
for the maintenance of healthy peri - implant tissue, but if we consider that the quality of plaque control can change during the course of years, the presence of ade-quate amount of attached mucosa is advocated (Schou et al., 1992 ).
Introduction to s urgical t echniques
Soft tissue management in areas of implant placement can be performed (i) before implant placement, (ii) during the second - stage surgery and before the pros-thetic phase, and (iii) after delivery of the fi nal crowns. We will focus on the different procedures the clinician can use with particular regard to the esthetic area.
The ideal solution of some cases requires a multidisci-plinary approach or multiple procedures with a precise timetable between each surgery. Some situations cannot be completely corrected because of biological limitations or a compromised starting point, and it is important to disclose this fully to the patient in order to avoid medico - legal involvements or unrealistic expectations. The general opinion regarding the best moment to correct soft tissue defects is that the earlier the intervention, the better the result. Although each situation is different and should be treated accordingly, the predictability of soft tissue augmentation is higher if the defi ciency is treated as soon as it appears. The clinician must also understand the difference between actual hard and soft tissue defi -ciencies and discrepancies seen during the natural course of healing. For instance, the maturation of interdental papilla after restoring a proper contact point takes a certain period of time as does socket remodeling postex-traction; ignorance regarding healing times may lead a clinician to overtreatment. Then again, some defects cannot be completely treated with one surgery only, and sometimes additional tissue augmentations are indicated after implant integration as refi nement of previous graft-ing. Moreover, additional surgeries may be necessary to correct situations with minimal residual KG or to augment or restore interimplant papillae for esthetic reasons.
Two indications exist that warrant soft tissue augmen-tation: (i) expanding the width of keratinized mucosa, as reviewed earlier; and (ii) expanding mucosal volume to attain a natural, cosmetic drape around the implant. In particular, implant recession and papillary regeneration will be addressed.
The methods to increase the amount of keratinized tissue are (i) apically positioned fl ap (APF), (ii) APF in combination with autogenous tissue, and (iii) APF in combination with allogenous tissue (Thoma et al., 2009 ). If the purpose is to gain more volume, FGG, subepithe-lial connective tissue graft ( CTG ), pedicle fl ap, or allografts could be viable alternatives (Cairo et al., 2008 ; Thoma et al., 2009 ).
a recent systematic review (Rajapakse et al., 2007 ) drew inconclusive results and pointed out that duration and frequency of brushing, technique, force, frequency of changing brushes, and type of bristles should be taken into account.
Before analyzing the role of KG around dental implants, it is important to summarize some existing dif-ferences of dental implants compared to natural teeth: absence of cementum and periodontal ligament, reduced blood supply, and fewer fi broblasts with a parallel orien-tation of the supracrestal fi bers along the abutment ’ s surface (Lindhe, 2008 ). The lack of periodontal ligament prevents an inductive establishment of a minimum amount of KG around implants. There is no attachment apparatus around implants like the one present in natural dentition, composed of collagen fi bers inserting into the dentin or the cementum of the root. These char-acteristics make dental implants more prone to the development of infl ammation and bone loss in case of plaque accumulation or bacterial invasion. An intact and stable biological seal around dental implants becomes fundamental for the long - term success of implant treatment.
Experimental investigations on animals showed that absence of keratinized mucosa increases plaque accumu-lation and causes bone loss (Warrer et al., 1995 ). Thirty implants were placed in the mandible of fi ve monkeys, in areas with and without keratinized mucosa. After a period of 3 months, all implant fi xtures were exposed to plaque accumulation, and around some of them cotton ligatures were applied. Ligated implants with no keratin-ized tissue showed signifi cant recession and bone loss compared with the other fi xtures (Warrer et al., 1995 ). In a human study, Kim et al. (2009) evaluated 276 implants in 100 patients with an average follow - up of 13 months and reported increased bone loss and mucosal recession around fi xtures with inadequate keratinized tissue. Similar results were found by Bouri et al. (2008) around 200 implants. Adibrad et al. (2009) analyzed 66 dental implants supporting overdentures and reported higher plaque accumulation, gingival infl ammation, and reces-sion of the soft tissue with less than 2 mm of keratinized mucosa. Chung et al. (2006) analyzed the success rates of implants with different surfaces in relation to the amount of keratinization. Only in the posterior area did they fi nd a relationship between higher plaque accumulation, infl ammation, and reduced attached mucosa, but there was no evidence of increased bone loss based on the amount of keratinized tissue. Moreover, the type of implant surface failed to demonstrate an infl uence on the periodontal index. They concluded that the hygiene of posterior implant - supported prostheses in close contact with the tissue might be diffi cult to maintain.
If a proper oral hygiene level is present, however, keratinized mucosa does not appear to be a requirement
Soft tissue enhancement after implant placement 363
Surgical t echniques: p reliminary c onsiderations
Proper patient selection, correct diagnosis, and apt treat-ment planned together with an adequate surgical and prosthodontic protocol are fundamental to the long - term success of implant restorations. Nowadays, with the increased expectations of patients, soft tissue man-agement in the anterior area can represent the most criti-cal and diffi cult part of the entire rehabilitation. Anatomical familiarity and biological knowledge of the area of interest are prerequisites for safe surgery and for choosing the right technique. During the last few years, a microsurgical approach has radically changed the way of treating soft tissue defects. The use of magnifi cation devices, microsurgical instruments, blades, and needles can make the difference in the fi nal result.
In presence of adequate keratinized tissue during second stage surgery, a tissue punch is used to remove just the tissue immediately over the cover screw, without raising a fl ap. This technique has the advantage of decreasing the morbidity for the patient and of speeding up the healing time before the impression phase. As no bone is exposed, there is a reduction in possible resorp-tion and scar formation. Yet useful keratinized tissue gets disposed. Alternatively, the simplest technique to build a soft tissue contour consists of dividing the mucosa in two halves through a midcrestal incision and in reposi-tioning equal amounts of tissue around buccal and lingual sides of the healing abutment. To combine a mini-mally invasive approach with an increase of keratinized mucosa at the buccal aspect of the implant, a semilunar incision over the cover screw has been recommended by Stappert (2007) . The semilunar incision should barely exceed the dimensions of the cover screw, sparing the proximal papillae (Fig. 20.1 ). The convex aspect of the incision points to the oral side of the alveolar ridge. By
Fig. 20.1 Second - stage minimally invasive semilunar incision to uncover two implants in central incisor sites #8 and #9.
Fig. 20.2 Repositioning of keratinized mucosa from the palatal to the buccal aspect and removal of the implant cover screws.
Fig. 20.3 Placement of customized computer - aided design/computer - aided manufacturing (CAD/CAM) - fabricated zirconium oxide abutments in implant sites #8 and #9 and following crown temporization. (Case courtesy of Dr. Christian F.J. Stappert.)
elevating the minifl ap over the cover screw, additional keratinized tissue is moved to the buccal side when the abutment is placed (Figs. 20.2 and 20.3 ). (Case courtesy of Dr. Christian F.J. Stappert, 2011.)
Frequently after ridge augmentation or bone grafting performed simultaneously with implant placement, fl ap release and coronal advancement is necessary to get primary closure of the wound. Consequently after healing, the mucogingival line may exist at a more coronal position, decreasing the amount of functional keratinized mucosa. Although the absence of keratinized mucosa may not compromise the long - term success of implant restorations, its presence improves esthetics, reduces plaque accumulation by improved cleansibility, and guarantees a stable mucosal seal. For those reasons, keratinized tissue augmentation may be indicated.
In 1954, Nabers proposed the concept of repositioning the attached gingiva by raising a full - thickness fl ap and displacing it apically in order to augment the amount of KG and to eliminate possible periodontal pockets. The alveolar bone was left exposed to the oral cavity, and this
364 Implant site development
mucosa, an FGG associated with a partial - thickness fl ap is desirable for more predictability and for the possibility of protecting the underlying connective tissue and bone (Fagan and Freeman, 1974 ; Sato, 2008 ).
An effective method to build up keratinized tissue around implants during second - stage surgery is by a modifi ed apically repositioned fl ap or even a laterally positioned fl ap, originally reported for teeth (Cairo et al., 2008 ). An incision may be made where the existing kera-tinized mucosa is more abundant, usually closer to the palatal or lingual side. A partial - thickness fl ap may then be raised and secured with sutures to the buccal side of the healing abutments. Healing occurs by secondary intention.
Case r eport #1: a pically r epositioned p artial - t hickness fl ap
This patient was diagnosed with generalized aggressive periodontitis, gingival infl ammation, plaque, and calcu-lus (Fig. 20.4 ). Radiographs illustrated severe bone loss, with prominent vertical defects around teeth #2, #4, #9, #11, #18, and #30, and horizontal bone resorption around the remaining dentition (Fig. 20.5 ), resulting in mobility grades II and III. Clinically, severe canine reces-sion was seen on both arches, though a wide band of KG remained in the maxilla (Fig. 20.6 ). After extractions, sinus lifts, and delayed implant placement (Fig. 20.7 ), a narrow band of keratinized tissue resulted mainly on the right side, with lining mucosa extended almost to the level of the crest and covering part of the implant heads (Fig. 20.8 ). The purpose of the second - stage surgery was to increase the amount and the thickness of the KG at the buccal aspect mainly. A linear incision was performed in approximately 4 – 5 - mm distance of the mucogingival line toward the palatal side, and a partial - thickness fl ap was
technique was called bone denudation (Ochsenbein, 1960 ; Wilderman, 1964 ). The major disadvantage was the severe bone loss (Costich and Ramfjord, 1968 ; Wilderman et al., 1961 ), which encouraged later clinicians to leave a layer of connective tissue and periosteum covering and protecting the bone (Pfeifer, 1965 ; Staffi leno et al., 1966 ; Wilderman, 1963 ). This new APF with the retention of the periosteum (split - or partial - thickness fl ap) has reduced but not completely eliminated bone resorption (Ramfjord and Costich, 1968 ). Residual width of at least 0.5 mm of tissue should cover the bone, especially in case of thin bone, to guarantee enough protection for the ridge and to avoid necrosis of this layer (Ramfjord and Ash, 1979 ). Besides, the partial - thickness fl ap should have a minimum thickness of ≥ 2.5 mm to ensure ade-quate blood supply, leading to at least ≥ 3 mm of gingival tissue to perform this kind of procedure.
The main difference between full - thickness and split - thickness fl ap is related to the presence or absence of periosteum covering the bone. From a histological point of view, periosteum is composed of an external layer rich of blood vessels, nerves, and dense collagen fi ber and an external part (osteogenous layer) abundant in cells but with a poor blood supply (Ruben et al., 1973 ). The healing after a full - thickness fl ap involves different processes taking place between the bone and the mucoperiosteal fl ap, while the partial - thickness fl ap creates an interface of periosteal connective tissue and connective tissue of the fl ap (Staffi leno, 1974 ); differences in the amount of involved tissue as well as the activity of tissue healing have been reported. In fact during a 6 – 8 - day period, only two or three reversal lines of circumferential lamellae show signs of resorption in case of a partial - thickness fl ap, while the same process extends to the Haversian system beyond the lamellae for a full - thickness fl ap. At the 14th day, osteoclastic activity is completed in the partial - thickness fl ap and only reduced in the full - thickness fl ap. At a 20 - day period, the alveolar bone asso-ciated with the split - thickness fl ap shows limited amount of reabsorption at the crestal level and on the vestibular side with an ongoing osteogenesis process, while the degree of resorption is much more evident at each side for the full - thickness fl ap, osteoclastic activity is still present, and osteogenesis is not yet initiated. After 60 days, a complete repair of the area takes place associ-ated with the partial - thickness fl ap, with no apical migra-tion of the attachment apparatus, whereas the full - thickness fl ap results in a modifi cation of the inner structure, changes in the attachment apparatus, and some osteogenesis activity still running.
In summary, the use of an apically positioned partial - thickness fl ap to increase the amount of KG is indicated in cases of adequate thickness of the gingival mucosa (at least ≥ 3 mm), good depth of the vestibule, and thick alveolar bone. In case of complete absence of keratinized
Fig. 20.4 Marginal gingival infl ammation associated with plaque and calcu-lus was observed around multiple teeth. Generalized periodontitis resulted in clinical attachment loss but a wide band of keratinized tissue was still present.
Soft tissue enhancement after implant placement 365
raised to expose the cover screws. At all times, the perios-teum and a minimum connective tissue layer of 0.5 – 1 mm thickness remained on the alveolar bone. The fl ap was moved to the buccal side, secured by horizontal sutures and compressed against the alveolar bone with mattress sutures (4 - 0 Prolene ® black, monofi l, Ethicon GmbH & Co. AG, Norderstedt, Germany). Part of the palate was left exposed to the oral cavity and left to heal via second intention (Fig. 20.9 ). After maturation of the tissue — which occurred in at least 3 weeks — adequate keratinized mucosa (a band of 2 mm or more) was detected circum-ferentially around each implant (Fig. 20.10 ). The con-struction of a custom - made titanium bar on the implants to retain an overdenture, with adequate space to ensure hygienic maintenance, was generated (Fig. 20.11 ). The prosthetic superstructure fulfi lled the need of hard and soft tissue replacement and provided adequate lip support. Good retention of the overdenture, based on the
Fig. 20.5 Periapical X - rays evidenced severe bone loss as a combination of vertical defects and horizontal resorption for most teeth.
Fig. 20.6 The occlusal view of the maxillary arch showed a dentition with multiple crown restorations and infl ammatory gingival tissue.
Fig. 20.7 Severe bone loss and active infl ammatory status led to extraction of the residual dentition in preparation for implant placement and upper implant - supported restoration. Healing resulted in reduction of keratinized gingiva and positioning of the mucogingival junction at the alveolar ridge at midcrestal level.
Fig. 20.8 Panoramic radiograph after bilateral sinus augmentations and implant placements in both arches.
Fig. 20.9 A split - thickness fl ap was raised containing a band of keratinized gingiva from the palate and secured on the buccal side of the healing abut-ments with monophilic sutures (4 - 0). The palate was left for healing by second intention.
366 Implant site development
tive techniques (Misch et al., 2004 ). The fi rst method, subtraction, removes tissue to get access to the cover screw and to defi ne the soft tissue contour, but generally, a reduction of papilla height is the consequence (Moy et al., 1989 ). The second method, addition, augments the peri - implant soft tissue using available adjacent tissue or connective tissue transplants as well as allografts (Adriaenssens et al., 1999 ; Azzi et al., 2002 ; Davidoff, 1996 ; Misch et al., 2004 ). Therefore, tissue volume of the recipient site, mainly buccal or interproximal of teeth or implants, increases.
FGG s
In case #1, a simple repositioning fl ap allowed for enough tissue gain to increase the thickness and the amount of KG on the buccal side. But when more kera-tinized tissue is required, at least 4 mm, and the amount available at the alveolar ridge is minimal or a thin phe-notype is present, an FGG is indicated.
The classic technique proposed by Bjorn in 1963 entails removing a piece of KG from the palate (donor site) and suture stabilization to the recipient site. The palatal donor site usually spans the area starting from fi rst pre-molar until the end of the fi rst molar, depending on the extent of the deformity; this zone is free of palatal rugae and relatively far away from important vascular and nervous structures.
Clinical investigations measured the thickness of the palatal mucosa with different techniques: bone sound-ing with a periodontal probe (Studer et al., 1997 ; Wara - Aswapati et al., 2001 ); ultrasonic device (Kydd et al., 1971 ; M ü ller et al., 2000 ); conventional computed tomography (CT) scan (Song et al., 2008 ); and cone beam CT (Barriviera et al., 2009 ). All studies evidenced increasing thickness moving from the gingival margin to the midpalate and from canine area to the second molar, with the exception
custom - made titanium bar and Swiss - lock components, made a coverage of the palate abdicable (Fig. 20.12 ). (Case courtesy of Dr. Christian F.J. Stappert, 2002.)
Different techniques have been developed over the years to minimize surgical trauma, avoid scarring in the esthetic area, and create natural soft tissue architecture around implants. Establishing the interimplant papilla certainly remains one of the most diffi cult challenges. A most recent trend is to maintain the existing tissue archi-tecture by placing an immediate implant in the fresh extraction socket and providing direct fi xed temporiza-tion to prevent the tissue from collapsing. This repre-sents a minimally invasive procedure limited to one surgery, but the cascade of events taking place after tooth extraction and the biological differences between teeth and implants makes this approach somewhat unpredictable.
As an alternative to immediate implantation, second - stage surgical intervention may be performed to create natural soft tissue architecture using subtractive or addi-
Fig. 20.11 A custom - made titanium bar was computer - aided design/computer - aided manufacturing (CAD/CAM) fabricated and screw retained. Alternate placement of the fi rst three implant screws was done to avoid misfi t of the bar construction.
Fig. 20.12 Esthetics and function were restored with implant overdentures fulfi lling the need of hard and soft tissue replacement for adequate lip support. (Case courtesy of Dr. Christian F.J. Stappert.)
Fig. 20.10 After tissue maturation, each implant head was surrounded by an adequate amount of attached keratinized tissue.
Soft tissue enhancement after implant placement 367
were carefully detached to ensure immobilization of the graft to the underlying periosteum, graft stability being one of the crucial keys to success. Healing abutments of adequate heights were connected to the implants, and the attached gingiva present in the area was moved to the lingual side of the abutments without detaching it from the bone (Fig. 20.14 ). Two FGGs 20 × 8 mm with an approximate thickness of 1.8 mm were taken from both sides of the palate; this guaranteed enough connective tissue for the survival of the graft during the fi rst days of healing (Figs. 20.15 and 20.16 ). A 4 - 0 chromic gut suture (Ethicon, Johnson & Johnson, Boston, MA) with a P3 needle was used to secure the graft; this material was chosen for its tensile strength, minimal infl amma-tory inducement, and fast enzymatic dissolution. The 3/8 circle needle 13 mm long guaranteed good manageabil-ity and a precise cutting power, with reduced trauma for the tissue. A few single interrupted sutures at the
on the fi rst molar because of the prominence of the palatal root. The canine - premolar area seems to be the most suitable donor site. The tuberosity also allows har-vesting a thick graft due to its abundant soft tissue, but the area of the graft is limited here.
Wara - Aswapati et al. (2001) analyzed the thickness of the mucosa in 62 fully dentate subjects with a bone sounding method, using a periodontal probe and an acrylic stent. Mean mucosal thickness ranged from 2.0 to 3.7 mm, with values of 4.3 and 6.1 mm close to the mid-palatal line of the fi rst and second molar sites, respec-tively. Variations were reported according to the age of the patient, showing an increase of mean tissue thick-ness (2.8 ± 0.3 mm vs. 3.1 ± 0.3 mm) for older subjects. Some authors documented a direct relationship between mucosal thickness and periodontal phenotype (M ü ller and Eger, 2002 ), body mass index (Schacher et al., 2010 ; Stipetic et al., 2005 ), and age (Barriviera et al., 2009 ; Song et al., 2008 ; Wara - Aswapati et al., 2001 ), while disagree-ment exists regarding association with gender (Barriviera et al., 2009 ; M ü ller et al., 2000 ; Schacher et al., 2010 ; Song et al., 2008 ; Wara - Aswapati et al., 2001 ).
Conditions necessary for the healing process include the presence of a thin graft in close and stable contact with the host tissue. A thick blood clot would delay the fl uid circulation during the fi rst part of healing and the creation of the vascular network, increasing the risk of necrosis. Thus, in order to avoid the creation of a hema-toma between the graft and the recipient site, it is advis-able to maintain pressure over the grafted site for approximately 5 minutes with wet gauze to prevent a dead space under the graft following suturing.
The graft should include the epithelial layer as well as the underlying connective tissue because its survival during the fi rst few hours is strictly dependent on its con-nective tissue bed; a graft composed of only epithelium will undergo necrosis because it lacks blood vessels. The mean thickness of orthokeratinized palatal epithelium has been reported as 0.31 mm (Schroeder, 1986 ), though there is variability up to 0.6 mm (Soehren et al., 1973 ).
Case r eport #2: e xtended FGG s at the m andible
The patient presented with two implants placed in the lower jaw meant to support an overdenture (Fig. 20.13 ). One implant head became exposed to the oral cavity, while the other was still covered by alveolar mucosa; however, in both sites, less than 4 mm of KG was present. Two FGGs were prepared to allow for simultaneous augmentation of the keratinized tissue and vestibule deepening. First, a partial - thickness recipient bed was prepared by sharp dissection 0.5 mm above the mucogin-gival junction with a 15c blade and muscle attachments
Fig. 20.13 Three months after two implants were placed for lower denture stabilization; a reduced amount of keratinized gingiva was recognized at the implant positions and the buccal alveolar ridge. The vestibule was shallow.
Fig. 20.14 A split - thickness fl ap was raised and all the keratinized tissue available were moved to the lingual side of the healing abutments. The muco-epithelial fl ap was stabilized apically in the vestibule by deep periosteal sutures.
368 Implant site development
superior corner of each graft maintained them close to the healing abutments and at the same time favored the establishment of blood supply to the fl ap. At the inferior border of the grafts, suturing to the periosteum occurred; additional mattress sutures compressed the graft against the periosteal bed to promote plasmatic circulation (Fig. 20.17 ). Pressure with wet gauze was maintained for 5 minutes onto the sutured grafts to reduce any dead space between the graft and the periosteum. The healing of the FGGs was reported after 1 month (Figs. 20.18 and 20.19 ). Complete maturation of the grafts occurred after 1 month, with full keratinization of the epithelial layer. A
Fig. 20.15 Free gingival grafts were taken from the palate with a 15c scalpel.
Fig. 20.16 Two FGGs with 20 - mm lengths and a good amount of connective tissue were harvested and adapted to fi t into the recipient site.
Fig. 20.17 The two FGGs were secured to the underlying periosteum with resorbable sutures. Additional vertical mattress sutures secured stabilization and blood supply.
Fig. 20.18 One month later a wide band of keratinized tissue surrounded the implants, with a good color match with the residual tissue.
Fig. 20.19 The depth of the vestibule has increased and the prosthetic reha-bilitation could be seated with greater stability 1 month after surgery. (Courtesy of Dr. Christian F.J. Stappert and Dr. Jose Per é z.)
Soft tissue enhancement after implant placement 369
depth without cutting the periosteum (Fig. 20.20 ). The split - thickness fl ap preparation is executed by more shallow crestal incisions ( ≤ 45 ° angle) following the alveo-lar ridge contour and maintaining a uniform layer of periosteum and at least 0.5 mm of crestal connective tissue. Special attention should be given during fl ap elevation at the curvature of the crestal and buccal bone. The use of atraumatic tissue pliers can reduce the risk of perforation during the change in direction of the blade. A suffi cient thickness of the buccal split - thickness fl ap is important on its borders to avoid necrosis due to com-promised blood supply. It is essential to thin out the crestal mucosal connective tissue at the base of the ves-tibule and disconnect muscle or ligament initiations to provide maximum tissue stabilization at the alveolar ridge (Fig. 20.21 ). The mobilized band of keratinized tissue at the coronal part of the buccal mucoepithelial fl ap helps to position the fl ap apically and to secure it to the underlying periosteum with deep single horizontal sutures. Proper stabilization of the buccal tissue will avoid mobility and displacement of the FGG during mastication and phonetics and will secure the reestab-lishment of the vascular network (Fig. 20.22 ). An FGG of at least 1.5 – 2 mm thickness should be taken from the palate with a 15c scalpel. The dimensions of the FGG should be rather smaller than the recipient side to allow for keratinization of exposed connective tissue by sec-ondary intention, which reduces scar tissue. The FGG will be transferred to the recipient site to create a new area of keratinized tissue (Fig. 20.23 ). The fi rst line of horizontal sutures stabilizes the graft at the coronal
natural blending with the preexisting keratinized tissue was detected, with distinct graft borders (Fig. 20.18 ). As a result, a wide band of keratinized tissue was present on the buccal side of the implants and the increased depth of the vestibule allowed for more stable prosthetic support (Fig. 20.19 ). Soft tissue contouring was required between the two fi xtures to facilitate hygienic proce-dures. (Case courtesy of Dr. Christian F.J. Stappert and Dr. Jose Per é z, 2007.)
Before considering a case of free gingival grafting in the maxillary arch, a description of the surgical tech-nique, step - by - step, will be provided.
FGG t echnique m odifi ed by S tappert: S tep - b y - s tep
In some situations, more frequently after ridge augmen-tation techniques, the mucogingival junction can be located close to the top of the alveolar crest. In order to increase the width of keratinized tissue, FGG placement is suggested. Before starting with the surgical procedure, specifi c attention should be given to the local anesthesia protocol. Procedures of soft tissue grafts and split - thickness fl aps are associated with greater bleeding. The use of articaine chlorhydrate 4% and adrenaline 1:100.000 (Alfacaina N, Weimer Pharma, Rastatt, Germany) are rec-ommended for several reasons. This anesthetic has a plasmatic metabolism, with a short life and no accumula-tion in the human body, giving clinicians the opportu-nity of using higher concentrations with limited risk of toxicity. Besides, its intrinsic constriction property pro-vides a strong anesthetic activity, 1.8 times greater than lidocaine. The injection should be done with adequate time (1 mL every minute), giving tissue the opportunity to absorb the product for a long - lasting effect. All these factors contribute to reduce the bleeding without creat-ing ischemic condition, increasing the comfort for the patient and the clinician. A 15c scalpel represents a good compromise between dimension of the blade and cutting power, but microsurgical instruments are admitted according to clinician habits. It is important to use sharp instruments during fl ap elevation and to avoid multiple incisions at different levels that result in tissue damage and compromised blood supply.
The preparation of the recipient site should start with a linear incision in the KG approximately 3 – 5 mm palatal of the mucogingival junction. The primary incision initi-ates at the KG of the palate, not at the buccal mucosal epithelium or the mucogingival junction, to reposition a band of KG further apical of the vestibule. Therefore, the FGG will be surrounded by KG coronally and apically. This technique avoids the creation of a nonkeratinized interface between the graft and the palate, which fre-quently results in scar tissue. The initial incision should be performed in a 90 ° angle and approximately 2 mm
Fig. 20.20 Linear incision in the palatal keratinized mucosa to prepare a split - thickness fl ap. It is important to leave a uniform layer of periosteum covering the bone to reduce crestal bone resorption.
370 Implant site development
Fig. 20.22 The fl ap should be secured with deep periosteal sutures to prevent mobility of the connective tissue above the mucoepithelial fl ap.
Fig. 20.23 Free gingival graft will be harvested from the palate, leaving the area exposed for a second - intention healing. The graft extension should be smaller than the recipient site to minimize scar tissue. The tissue transplant should be placed directly onto the recipient site with only minor adjustments.
Fig. 20.24 First, the fl ap should be fi xed by interrupted horizontal sutures at the coronal and vestibule fl ap margins. The secondary vertical and horizontal mattress sutures span over the FGG and lock the graft onto the underlying periosteum to establish plasmatic circulation. (Graphics on the modifi ed FGG technique courtesy of Dr. Christian F.J. Stappert.)
Clinical fi ndings evidenced a shallow vestibule, with unattached mucosa approximating the abutment levels of the anterior implants (Fig. 20.26 ). The implant posi-tions were approximately 8 mm further lingual than the restored anterior tooth positions. Therefore, the upper lip was constantly rubbing over the fi xed dental prosthe-sis and food impaction was evident (Fig. 20.27 ). It was proposed to take FGGs from both sides of the palate to
Fig. 20.21 The mucoepithelial fl ap should be positioned apically in the ves-tibule on the buccal side.
border of the recipient site and the apical border close to the mucoepithelial fl ap. Pressure is applied to the graft with wet gauze for a few minutes and interrupted over-spanning sutures stabilize the graft to the underlying periosteum to maintain a close contact between the con-nective tissue of the graft and the recipient bed (Fig. 20.24 ). (Graphics courtesy of Dr. Christian F.J. Stappert.)
Case r eport #3: e xtended FGG s at the m axilla
A 55 - year - old male patient presented with full - arch max-illary implant rehabilitation (Fig. 20.25 ), reporting per-sisting sore spots at the inner part of the upper lip.
Soft tissue enhancement after implant placement 371
Fig. 20.25 The panoramic radiograph demonstrates a full - arch rehabilitation with bilateral sinus augmentations and multiple - implant placements. The patient has a compromised upper implant - supported fi xed dental prosthesis.
Fig. 20.26 A narrow band of keratinized tissue surrounded some of the fi x-tures on the buccal side of the anterior maxilla.
Fig. 20.27 The shallow vestibule caused food impaction. Rubbing of the labial mucosa over the resin base of the fi xed dental prosthesis created labial sore spots for the patient repeatedly.
Fig. 20.28 An increase of keratinized gingiva was planned. A split - thickness fl ap was raised buccally from the second bicuspids of both sides to the anterior dentition without vertical incisions. Muscle insertions were carefully detached.
move the mucogingival junction more apically to increase patient comfort. A linear incision in the KG close to the implant heads was performed and a split - thickness fl ap was raised with complete muscle dissection (Fig. 20.28 ). The fl ap was fi rmly secured to the periosteum with single interrupted sutures to avoid any apical movement (5 - 0 GORE - TEX ® sutures, nonabsorbable monofi lament, W.L. Gore & Associates, Flagstaff, AZ) (Fig. 20.29 ). Two FGGs were taken as previously described (Fig. 20.30 ) and reshaped to fi t the recipient sites (Fig. 20.31 ). The FGGs were sutured to the buccal mucosal connective tissue and to the underlying periosteum (5 - 0 and 6 - 0 GORE - TEX ® sutures, nonabsorbable monofi lament) (Fig. 20.32 ). After 2 weeks, a creation of a band of keratinized mucosa between the interfaces of the grafts was evident (Fig. 20.33 ). Two months after, a new depth of the vestibule was established (Fig. 20.34 ). The mucogingival junction was repositioned approximately 10 – 12 mm apical to its presurgical level (Fig. 20.35 ). The 1 - year follow - up
Fig. 20.29 The mucoepithelial fl ap was positioned apically and secured with periosteal sutures to create a recipient site for free gingival grafts.
Fig. 20.31 The grafts were adapted to the recipient areas to increase the height of keratinized gingiva on the buccal side.
Fig. 20.32 The grafts were secured to the periosteum and to the palatal keratinized gingiva to guarantee immobilization during the healing phase.
Fig. 20.33 Two weeks after surgery, the buccal view of the surgical area showed fi brin clot resolution and signs of revascularization.
Fig. 20.34 After 2 months, the depth of the vestibule was improved and an increased band of keratinized gingiva was evident.
Fig. 20.35 The mucogingival junction was positioned approximately 10 – 12 mm further apical than its location before the surgery, providing a stable band of keratinized gingiva around the implants.
Fig. 20.30 Two free gingival grafts were taken from the palate.
372
Soft tissue enhancement after implant placement 373
showed stable tissue results and improved cleansibility after insertion of a new prosthetic restoration (Fig. 20.36 ). (Case courtesy of Dr. Christian F.J. Stappert and Dr. Yasufumi Hanawa, 2008.)
CTG
In some clinical situations, an adequate width of keratin-ized tissue is present around implants, but if we consider all dimensional aspects, especially in the anterior area, a lack of volume can decrease our perception of an esthetic outcome. The main reasons to increase the volume of the soft tissue contour are to improve the emergence profi le of implant - supported fi xed restorations and to hide any metal abutment - caused color discrepancies in the esthetic zone. Hard or soft tissue defi ciencies or a combination of both can be reduced or completely corrected with an autogenous CTG. This procedure can be done during the second - stage surgery, at the time of temporization, or even after the fi nal restoration. Yet, the outcome of soft tissue surgery on fi nal implant restorations is far less predictable.
Common donor sites are the palate or the tuberosity areas. The retromolar pad, especially after extraction of third molar, offers connective tissue rich in collagen fi bers that can guarantee better graft stability and less resorption over time. As discussed before, the palatal donor site is usually represented by the area starting from fi rst premolar to the end of the fi rst molar where the quality of graft is composed of dense connective tissue and a good compromise between adipose tissue, predominant in the anterior hard palate, and minor sali-vary glands, abundant in the posterior hard palate (DuBrul, 1988 ; Studer et al., 1997 ).
Preliminary consideration of the harvest area should be completed to evaluate the amount of tissue from donor sites before the surgical procedure. An injection
Fig. 20.36 The 1 - year follow - up revealed a stable result after insertion of a new prosthetic restoration. (Courtesy of Dr. Christian F.J. Stappert and Dr. Yasufumi Hanawa.)
needle with an endodontic stop can be used to probe the palatal mucosa after anesthetic injection. As mentioned before, tissue thickness can be related to the periodontal phenotype, body mass index, and age. Attention should be given to the anatomy and shape of the palate to iden-tify the potential palatal artery path. Usually, high palatal vaults are associated with a deep position of vessels and nerves, allowing clinicians a relatively risk - free proce-dure compared with that performed in a wide and shallow maxillary arch.
Before taking the graft, the preparation of the recipi-ent site is mandatory. A split - thickness fl ap should be raised and, whenever possible, vertical incisions avoided or at least minimized to secure good blood supply. The key is to maintain and guarantee an effi cient blood vessel network for the survival of the graft to establish new vascularization. The creation of an envelope for the sub-epithelial CTG can provide a double source of nutrition: the one from the connective tissue of the underlying periosteum and the one from the overlying fl ap. Besides, presence of the periosteal layer provides protection of the bone, reducing bone resorption, and offers mechani-cal retention for mattress sutures. Stabilization of the graft is fundamental for the promotion of plasmatic circulation.
When the creation of the recipient site is completed, the clinician gains a general idea of the necessary dimen-sions of the CTG. Different methods can be used to harvest the subepithelial connective tissue, but we suggest strongly a modifi ed “ single incision ” approach for reduced morbidity and discomfort of the patient (Del Pizzo et al., 2002 ; Lin and Weisgold, 2002 ). Horizontal incision perpendicular to the bone should be performed at least 4 mm apical to the gingival margin of premolars and fi rst molar to avoid any interference with the peri-odontal attachment of the teeth. The length of the inci-sion is related to the size of the graft. The fi rst incision does not perforate the periosteum, but is the initiation of a split - thickness fl ap toward the midline of the palate. After the overlying mucoepithelial fl ap is created, a second incision should be conducted 1 mm below and parallel to the fi rst incision, cutting the connective tissue including the periosteum (modifi cation). The extension of the CTG will be defi ned then by cutting the connec-tive tissue circumferential down to the bone level. The CTG is mobilized by periosteal elevation from the palatal bone and removed from the palatal donor site. The time elapsing between the harvesting and the positioning in the recipient site should be reduced to the minimum to avoid graft contamination and maintain its moisturizing. The palatal donor site should be kept under pressure with wet gauze for a few minutes to reduce bleeding. Palatal suspension sutures for primary closure should be performed after the surgical procedure at the recipient site is completed (Figs. 20.44 and 20.61 ).
374 Implant site development
Case r eport #4: CTG s — the e nvelope t echnique
The 42 - year - old patient was eager to improve his dental function and his smile. He presented with gingival infl ammation and multiple porcelain - fused - to - metal crowns and fi xed dental prostheses in both arches, the majority of them with improper margins and secondary decay (Fig. 20.37 ). The patient underwent extensive dental treatment including periodontal and endodontic treatment as well as implant placement in the edentulous sites. Considering only the maxillary anterior region, the right central incisor was missing and one implant was placed including guided bone regeneration with a two - stage approach (Fig. 20.38 ). Six months later, a slight con-cavity was noted on the buccal side of the implant and a CTG was proposed to improve the soft tissue contour before fi nal restoration (Fig. 20.39 ). The recipient site was prepared by intrasulcular incisions and a palatal posi-tioned crestal incision connecting the palatal line angles
Fig. 20.37 Multiple insuffi cient metal ceramic restorations were present in both arches. Tooth #8 was missing and replaced by an ovoid pontic of a fi xed dental prosthesis. Patient ’ s chief complaints were compromised anterior esthetics and masticatory function.
Fig. 20.38 The panoramic X - ray demonstrated the midterm results of the endodontic and surgical treatment phase. Bone - level implants were replaced in sites #2, #4, #8, #18, and #26 with second - stage approach.
Fig. 20.39 At the time of the second - stage surgery, a buccal concavity was present on the buccal side of implant #8.
Fig. 20.40 Split - thickness fl ap with a palatal approach was raised and no vertical incisions were performed to avoid scarring in the esthetic zone. The fl ap preparation was extended over the mucogingival junction to create an envelope.
of adjacent teeth. A split - thickness fl ap was raised by maintaining an intact periosteum and crestal connective tissue layer, resulting in the creation of a buccal envelope. The incision was extended beyond the mucogingival junction to allow for fl ap mobility and guarantee tension - free closure (Fig. 20.40 ). A CTG of 14 mm length was harvested from the palate by modifi ed single - incision technique as previously described (Fig. 20.41 ). It was inserted into the soft tissue envelope (Fig. 20.42 ) and stabilized by resolvable sutures (5 - 0 Vicryl ® , Ethicon) to the underlying periosteum and the overlying mucogin-gival fl ap. Single monophilic sutures provided primary closure of the overlying fl ap (Fig. 20.43 ). The palatal wound was secured by running sutures, embracing the adjacent teeth, spanning over the donor site and anchored horizontally in the apical intact tissue of the palate (Fig. 20.44 ). One month later, a custom - made zirconium oxide abutment was delivered and a fi xed provisional inserted (Fig. 20.45 ). Aluminum oxide all - ceramic crowns were fabricated for the anterior dentition (Fig. 20.46 ) and
Fig. 20.41 Connective tissue graft (CTG) was taken from the palate.
Fig. 20.42 The CTG was placed in the envelope between buccal and perios-teal connective tissue to correct the tissue defi ciency and to improve the emergence profi le of the restoration.
Fig. 20.43 The graft was stabilized to the underlying periosteum with resorb-able mattress sutures. The CTG was completely covered by the mucogingival fl ap.
Fig. 20.44 The palatal wound at the donor site was closed by primary inten-tion to reduce pain and morbidity for the patient.
Fig. 20.45 One month later a custom - made zirconium oxide abutment was placed on the implant and a fi xed provisional inserted. At this stage the soft tissue had reached a good stability.
Fig. 20.46 Aluminum oxide all - ceramic crowns were fabricated for the ante-rior teeth and the implant.
375
376 Implant site development
adhesively bonded to the natural teeth and implant (Fig. 20.47 ). The panoramic radiograph demonstrated the fi nal result of the full - mouth rehabilitation including site #8 (Fig. 20.48 ). One year after insertion of the permanent anterior all - ceramic restorations, the patient showed healthy and esthetically pleasing soft tissue conditions (Fig. 20.49 ). (Case courtesy of Dr. Christian F.J. Stappert, 2003.)
Case r eport #5: CTG s — modifi ed t unnel t echnique
A 45 - year - old female patient had tooth #9 extracted due to a vertical fracture, and a bone - level implant was placed immediately (4.1 × 12 mm). After 3 months of healing, a second - stage surgery was performed, and a provisional crown was placed at the day of surgery using a temporary cylinder. Ten weeks later, soft tissue healing
Fig. 20.47 Harmony of gingival margins was obtained bilaterally with absence of gingival infl ammation.
Fig. 20.48 The panoramic X - ray showed the fi nal prosthetic result, with aluminum oxide restorations of the anterior teeth and implant #8 until the second bicuspids bilaterally.
Fig. 20.49 Natural integration between gingival tissue and the anterior res-torations was obtained 6 months to 1 year after insertion of the nonmetal crowns. (Case courtesy of Dr. Christian F.J. Stappert.)
Fig. 20.50 Implant site #9 showed provisional crown with satisfactory papilla heights and slight marginal soft tissue recession at the cervical zenith.
was satisfactory with respect to the papilla heights of site #9 (Fig. 20.50 ). The occlusal view revealed a slight crestal undercontour of the cervical soft tissue dimensions (Fig. 20.51 ). It was thought to correct this defi cit by better tissue support with the permanent implant abutment. Therefore, two polyether impressions were taken, one on implant level and one utilizing the screw - retained temporary to transfer the soft tissue contour to a soft tissue model (Elian et al., 2007 ) (Figs. 20.52 and 20.53 ). A zirconium oxide custom - made abutment and all - ceramic crown were fabricated as the fi nal restoration and deliv-ered to the patient. Two weeks later, a recession of the cervical area was noted vertically (Fig. 20.54 ) as well as horizontally (Fig. 20.55 ). A modifi ed microsurgical tunnel technique was utilized to correct the recession at implant site #9 as well as the tissue contour of the neighboring teeth (Zuhr et al., 2007 ). The surgical procedure was accomplished by intrasulcular incisions and supraperios-teal split - thickness preparation of the buccal gingiva through the primary incision lines (Fig. 20.56 ). Initial
Soft tissue enhancement after implant placement 377
intrasulcular incisions were performed with microsurgi-cal blades. Microsurgical blades have cutting edges on both sides and on the tip of the blade, which minimizes the risk of tissue rupture. To gain mobility, the under-mining preparation had to be extended into the mucosal tissue beyond the mucogingival junction. Tunneling knives (tunneling knives 1 and 2, Mamadent, American Dental Systems GmbH, Vaterstetten, Germany) were used to achieve the tunneling preparation. The split - thickness dissection was extended to the distal line angles of the two adjacent teeth. The split - thickness fl ap resulted in a good blood supply for the subepithelial
Fig. 20.51 The palatal view of implant site #9 revealed a cervical undercon-tour of the marginal soft tissue dimensions.
Fig. 20.52 A polyether impression was taken utilizing the screw - retained temporary to transfer the soft tissue contour and implant position for a soft tissue model.
Fig. 20.53 The soft tissue model showed the implant position #9 (implant analogue) and the unchanged tissue conditions at the presence of the tem-porary implant abutment. The model was used to generate a custom - made zirconium oxide abutment.
Fig. 20.54 Final zirconium oxide abutment and all - ceramic crown 2 weeks after delivery. A vertical recession of the cervical area of site #9 was noted.
Fig. 20.55 The buccal view of the implant site #9 revealed horizontal soft tissue volume loss. The gingival zenith of the implant restoration was approximately 1.5 mm further apical than the zenith of the natural central incisor #8.
378 Implant site development
CTG since the periosteum stayed intact. The papilla areas were raised as full - thickness tissue including the periosteum, which allowed them to detach completely. This was done with a small tissue elevator to avoid risk of rapture. A CTG was harvested from the palate by single - incision technique as described previously (H ü rzeler and Weng, 1999 ) (Fig. 20.57 ). The CTG was inserted into the “ tunnel ” from the intrasulcular incision of tooth #8 (Fig. 20.58 ) and positioned under the muco-gingival split - thickness fl ap of sites #8 to #10 (Fig. 20.59 ). To do so, a support suture was used to guide the CTG into the recipient site. The suture was moved through each tunneled interdental area and was then secured in the CTG. By pulling the suture, the graft was gently
Fig. 20.57 A connective tissue graft of approximately 15 mm length was harvested from the palate by single - incision technique.
Fig. 20.58 The connective tissue graft was inserted into the “ tunnel ” from an intrasulcular incision of tooth #8. The CTG was secured by a suture and gently pulled under the mucoepithelial tissue of sites #8 to #10.
Fig. 20.59 The connective tissue graft was positioned under the keratinized tissue of sites #8 to #10. The papilla areas maintained in full thickness includ-ing the periosteum and stayed intact.
pushed into the tunneled tissue with a packing instru-ment. A vertical mattress suture (7 - 0 polypropylene, Blue Perma Sharp Sutures, HuFriedy Mfg. Co., Chicago, IL) was applied to elevate the entire gingivopapillary tissue coronally (Fig. 20.60 ). The suture had to capture the buccal fl ap and the subepithelial connective tissue to stabilize the CTG. The donor site was closed by running sutures spanning over the palatal wound (4 - 0 Vicryl ® ) (Fig. 20.61 ). Healing was uneventful and the marginal tissue level of site #9 was reestablished 2 months after surgery (Figs. 20.62 and 20.63 ). The periapical X - ray dem-onstrated stable crestal bone conditions (Fig. 20.64 ). (Case courtesy of Dr. Notis Emmanouilidis and Dr. Christian F.J. Stappert, 2010.)
Fig. 20.56 Intrasulcular incision at implant site #9 and supraperiosteal split - thickness preparation of the buccal gingiva through the primary incision line were performed using a microsurgical blade. Supraperiosteal undermining preparation of the mucosal tissue beyond the mucogingival junction was executed with a small tissue elevator to avoid the risk of rupture.
Soft tissue enhancement after implant placement 379
Fig. 20.60 A vertical mattress suture elevated the entire gingivopapillary tissue coronally. Temporary interproximal composite stops were used to secure the suture at the incisal edges.
Fig. 20.61 Closure of the donor site was achieved with running sutures span-ning over the palatal wound. The sutures provide coverage and protection of the donor site over the different stages of swelling and healing of the palatal tissue.
Fig. 20.62 The marginal peri - implant tissue level of site #9 was satisfactory after 2 months of tissue healing. Creeping epithelium was observed on teeth #8 and #10.
Fig. 20.63 The buccal connective tissue volume was improved for the four anterior incisor sites. Symmetry of gingival levels was reestablished.
Fig. 20.64 Stable crestal bone conditions were observed around the bone - level implant with zirconium oxide abutment and restoration by periapical X - ray evaluation. (Case courtesy of Dr. Notis Emmanouilidis and Dr. Christian F.J. Stappert.)
Conclusion
Soft tissue management is one of the key factors for suc-cessful implant restoration. Esthetics can be strongly infl uenced by the conditions of the peri - implant tissue. Substantial knowledge of tissue anatomy and biology is a fundamental prerequisite for surgical success.
The present chapter introduced different techniques to improve the appearance of the soft tissue after implant placement. Cases of repositioned fl aps, FGGs, and CTGs were presented along with biological considerations. It
380 Implant site development
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was our intention to present various indications and options to the clinician to achieve an increased amount of peri - implant KG or connective tissue thickness.
Stabilization of a tissue transplant as well as preserva-tion of blood supply at the recipient site and donor site are key factors for uneventful healing. Minimally inva-sive techniques involve smaller fl ap designs, mainte-nance of the periosteum – bone interface, and fewer vertical incisions. Microsurgical instruments and thinner suture materials allow for gentle handling of the delicate soft tissue conditions in the esthetic zone.
The fi nal goal is always a combination of long - term stability of the peri - implant tissue, implant restoration, and patient satisfaction.
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