Soft tissue procedures

19. Soft Tissue Procedures

Moustafa H El-Ghareeb BDS MS The Surgical Implant Center UCLA School of Dentistry

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Anatomy & Biology of Peri-Implant Soft Tissue

Similarities betwee periodontal & peri-implant ST: ! Oral epithelium ! Sulcular epithelium ! Junctional epithelium

Differences in peri-implant ST include: ! Lack of CT attachment ! Hypovascular,

hypocellular CT zone adjacent to the implant

! Absence of periodontal ligament blood supply

Sclar AG, 2003

Clinical Exam

Hard Tissue Assessment: Esthetic soft tissue results rely on good bony foundation ! The height of the alveolar crest at

adjacent teeth or in between 2 dental implants is responsible for supporting the interdental papilla

! The height and thickness of the facial bone wall is responsible for supporting the overlying marginal gingiva & provides soft tissue framing

! In order to obtain good esthetic ST outcome, hard tissue defects (vertical &/or horizontal) should be reconstructed prior to implant placement

The systematic evaluation of the esthetic implant patient starts with assessment of the underlying hard tissue

Crestal Bone Facial bone wall

Buser D, 2004

Clinical Exam Facial & ST Assessment:

Upper lip line: ! At rest, relaxed, & fully

animated ! Determine how much of teeth &

soft tissue is visible during maximal smile

! Most common tooth/gingiva to lip relationship on maximal smiling reveals the entire clinical crowns & interdental papillae

! This relationship determines what therapeutic modalities will be needed to obtain an esthetic result

! A high esthetic result is crucial with significant gingival display

High Smile Line

Low lip line

Clinical Exam

! Most common display in

the population includes the second bicuspid

! Next common is equally divided between first molar & first bicuspid

! Clinical relevance: significant display of posterior dentition & gingival tissues expands the esthetic zone beyond the anterior region (sites #6-11)

Number of teeth visible during smiling

Clinical Exam Mucosal characteristics: ! Assess amount of keratinized mucosa ! Ideally ≥ 3 mm of keratinized mucosa

around implants ! Attached mucosa is preferable but

unattached has been successful when oral hygiene is adequate (Mericske-Stern 1990)

! Attached mucosa : 1.  Provides a “prosthetic-friendly”

environment 2.  Facilitates OH maintenance required for

long-term success 3.  Resists recession 4.  Maintains predictable levels over time 5.  Enhances esthetic blending

Fully Edentulous

Partially Edentulous

Clinical Exam Gingival biotype: Thick blunted: ü  Resists recession & reacts to

surgical & restorative insults with pocket formation

Thin scalloped: ü  Attached soft tissue is minimal ü  Bony dehiscence & fenestration

defects characterize the underlying osseous structure

ü  Reacts to surgical or restorative interventions with ST recession, apical migration of attachment & loss of underlying alveolar volume

Thick Blunted

Thin Scalloped

Clinical Exam Gingival margin/outline: •  Sinuous versus

straight gingival pattern

•  Symmetry, asymmetry

distracts from the esthetic appearance of the patient’s smile

Straight pattern Sinuous pattern

Discrepancy in gingival margin positions

Clinical Exam

! Class I: Intact or slightly reduced papilla

! Class II: Limited loss of papilla

! Class III: Severe loss of papilla

! Class IV: Absence of papilla Papilla score (Ryser et al

2005): •  4=papilla fills the entire

interdental space •  3=>50% of the space filled •  2=<50% of the space filled •  1=no papilla present

I II

III IV

Palacci 2001

Interdental papilla evaluation: Palacci classification (Palacci 2001

Soft Tissue Surgical Procedures

Timing ! Before dental implant placement ! At the time of dental implant placement ! At the time of second stage surgery ! After implant restoration (least desirable)

Soft Tissue Surgical Procedures At Time of Second Stage Surgery

! Assess amount of keratinized mucosa and proceed accordingly

! Different techniques in different situations:

ü  Tissue punch or Scalloping ü  Midcrestal incision ü  Crestal incision but more

palatal ü  Full thickness flap ü  Partial thickness flap with

apical repositioning ü  Pedicle rotational flaps

(papilla regeneration)


Tissue Punch & Scalloping: ! Indicated only when the

volume & architecture of the peri-implant ST are ideal (i.e. wide thick band of keratinized ST)

! Orient the punch more palatally to preserve excess ST volume on the facial aspect


ST punch cannot be used with limited amount of keratinized mucosa


ST punch & scalloping techniques

Soft-tissue punch

Scalloping technique

Punch & scalloping technique


Full-thickness flap technique

Reverse soft-tissue architecture

Full-thickness flap technique

Full thickness flap technique

H incision (full thickness flap)


Palacci papilla regeneration technique

Palacci 2001

Palacci double pedicle flaps

Can be performed only when adequate amount of keratinized mucosa is available


Palacci papilla regeneration technique

Rotation of pedicle flaps

Semi-lunar bevel incision Pedicle flaps

Palacci, 2001


! Can be utilized to increase zone of attached tissue with limitations secondary to contracture

! Apical repositioned flaps are sutured to the periosteum (arrows)

! A soft lined CD is provided to protect site, improve patient comfort & minimize relapse

Sharp supra-periosteal

dissection

Narrow zone of keratinized

mucosa

Partial thickness flap Is apically repositioned

& sutured to periosteum

Partial thickness flap with apical repositioning:

Soft Tissue Surgical Procedures Preparation of recipient site: ! Ensure adequate vascularity to

support the graft (initial survival is by plasmatic diffusion )

! Provide a means of rigid immobilization of the graft (mobility disrupts the newly forming circulatory support)

! Prepare uniform surface for intimate graft adaptation

! Obtain hemostasis ü  hemorrhage prevents intimate

adaptation of the graft to underlying bed through fibrin layer

ü  Fibrin attaches graft to bed & provides for the plasmatic diffusion

Management of donor tissue: ! Harvest graft of adequate size to

take advantage of peripheral circulation

! Ensure a uniform graft surface for adaptation of recipient site

! Ensure adequate thickness to obtain desired volume augmentation & for survival over avascular surfaces

Free palatal & CT grafts


Indications of free palatal grafts:

! ST augmentations in non

esthetic areas ! To increases the zone of

keratinized tissue around implants

Note distinct margins & poor esthetic blending with surrounding tissue

Soft Tissue Surgical Procedures Free palatal Grafts (free gingival

grafts): ! Donor tissue is sized to recipient-

site dimensions ! Anterior incision is beveled to

facilitate localization of appropriate plane of dissection

! A thick split-thickness graft approaching full thickness is preferred (1.25-1.75 mm) when abutment coverage is desired

! Primary contraction is negligible with palatal grafts

! Secondary contraction is rarely a problem with thick split thickness grafts.

Soft Tissue Surgical Procedures Free palatal graft harvest: ! Apply gentle traction with tissue

forceps ! A uniform graft is harvested with

sharp dissection ! Hemostasis is achieved with

electrocautery ! The donor site is dressed with

absorbable collagen ! A palatal stent or a soft lined

maxillary CD is provided to protect site & improve patient comfort

Donor site 4 weeks after surgery Adequate hemostasis achieved


Creation of a uniform periosteal recipient site

Immobilization of graft at recipient site

One-year postoperative view Note secondary contraction (arrow)

Atrophic MN with thin band of attached ST

Free palatal graft

One week postoperative: Superficial epithelial

sloughing & initial revascularization


Indications of subepithelial CT grafts:

! ST augmentation in esthetic

areas due to superior color match & esthetic blending

! To provide a zone of attached non mobile ST around implants

! ? The underlying CT will determine the character of the overlying epithelium

! To enhance ST contours ! To reconstruct missing ST

volume defects


CT graft harvest: ! Blade is oriented parallel to surface of

palatal tissue ! CT graft is harvested ! Absorbable collagen dressing is used

to obliterate dead space ! Donor site is closed primarily ! A palatal stent may be used to support

palatal tissue & prevent hematoma formation

Soft Tissue Surgical Procedures Subepithelial CT graft recipient site: ! Has dual blood supply to support

graft revascularization (from periosteum & partial thickness cover flap or periosteum & bone surface)

Tunneling technique

Partial thickness MP flap reflection CT graft sutured to underlying periosteum

Full thickness MP flap reflection CT graft sutured to the periosteal side of the flap

References: ! Sclar AG. Soft tissue and esthetic considerations in implant

therapy. Quintessence, 2003 ! Palacci P. Esthetic implant dentistry: Soft and hard tissue

management. Quintessence, 2001 ! Buser D, Martin W, & Belser UC. Optimizing esthetics for

implant restorations in the anterior maxilla: Anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2004;19 Suppl:43-61

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Soft tissue procedures