Soft tissue grafting around implants
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Transcript of Soft tissue grafting around implants
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SOFT TISSUE ANATOMY & GRAFTING PROCEDURS AROUND
DENTAL IMPLANTS
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Importance of soft tissue integration
• Anchorage of the implant to bone
• Soft tissue seal around dental implants, equally
important for long term clinical success
• Understanding of both periodontal and peri-
implant anatomy & biology
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Anatomy of periodontal and peri-implant soft tissues
• Periodontal soft tissue anatomy
• Connective tissue attachment below the
alveolar crest
1. PDL fibers
2. Sharpey’s fibers
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• Connective tissue attachment above the
alveolar crest
1. Transseptal fibers
2. Dentogingival/dentoperiosteal fibers
3. Circular fibers
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• Epithelial tissue attachment
1. Oral epithelium
2. Sulcular epithelium
3. Junctional epithelium
• Vascular supply
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• Peri-implant soft tissue anatomy
1. Epithelial tissue attachment
2. Connective tissue attachment
• Splicing of fibers - Alveolar crest to free
gingiva and circular CT fibers running
circumferentially around the implant
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NEED & RATIONALE
FOR ATTACHED PERI-IMPLANT
SOFT TISSUES
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Comparison of the interface
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Difference in vascular supply
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PERMUCOSAL SEAL
Choosing between a submerged and
nonsubmerged approach
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Peri-implant plastic surgery
• Peri-implant plastic surgery focuses on
harmonizing peri-implant structures by means of
hard tissue engineering and soft tissue
engineering, and includes: bone structure
enhancement; soft tissue enhancement; precision
in implant placement; and quality of the
prosthetic restoration.
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SOFT TISSUE GRAFTING IN IMPLANT THERAPY
• 1959 Friedman : Mucogingival surgery
• 1980 : Paradigm shift
• 1988 Miller : Periodontal plastic surgery
• 1996 : Defined as
Surgical procedures performed to prevent or correct
anatomic, developmental, traumatic or disease
induced defects of the gingiva, alveolar mucosa or
bone
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Periodontal plastic Procedures
• Augmentation of attached tissues surrounding
natural teeth and implant restorations
• Root and implant abutment coverage
• Correction of mucogingival defects around
implants
• Edentulous ridge augmentation in preparation for
prosthetic rehabilitation with conventional or
implant prosthesis
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• Edentulous ridge preservation following tooth
removal in preparation for prosthetic rehabilitation
with conventional or implant prosthesis
• Management of aberrant frenula
• Preservation or reconstruction of interdental or
inter-implant papillae
• Surgical soft tissue sculpting procedures
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Oral soft tissue grafting with dental implants
Rationale for soft tissue grafting
• “Adequate zone” of attached tissue
• Withstand potential bacterial and mechanical
challenges
• Maynard and Wilson
• Adequate band of gingival tissues - 5mm around a
natural tooth
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• Lack of connective tissue, difference in composition,
vascularity and orientation of connective tissue
surrounding a dental implant – More susceptible to
disease
• Abutment connection, implant level impressions and
implant supported removable prosthesis – disruption of
soft tissue seal, apical migration of tissues and crestal
bone loss
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Surgical principles of soft tissue grafting
• Related to preparing the recipient site and those
related to harvesting & securing the donor tissue at
the graft site
• First principle : Recipient site must provide for
graft vascularization
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• Second principle : Recipient site must provide a
means for rigid immobilization of the graft tissue
• Third principle : Adequate hemostasis must be
obtained at the recipient site
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• Fourth principle : Donor tissue must be large enough
to facilitate immobilization at the recipient site and to
take advantage of the peripheral circulation when root
or abutment coverage is the goal
• Finally adequate graft thickness is essential
1.25mm preferable
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Modified palatal roll technique for dental implants
• Abrams 1980
• For deficient edentulous ridges for fixed
maxillary prosthesis
• Scharf and Tarnow 1992
• Modification of Abrams technique : “Trap
door” approach
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• Reikie 1995
• Application of trap door modification to enhance
soft tissue contours around dental implant
abutments
• Limited use in maxillary anterior area
• Performed in conjunction with second stage for
submerged & simultaneously with non-submerged
implant placement
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Modified roll technique
• Most favorable palatal anatomy : located between
canine and first molar
Cross section of maxillary alveolar ridge Full thickness incisions outline the
underlying CT pedicle
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CT pedicle is elevated
CT pedicle is rolled & secured in buccal pouch
Performed simultaneous with nonsubmerged implant placement
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Premolar implant site with soft tissue defect on buccal aspect
Elevation of split thickness palatal flap CT pedicle elevated with Adsons forceps
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Subperiosteal dissection extended to create buccal pouch with vertical release
CT pedicle adapted after one piece nonsubmerged implant placed
Suturing of vertical incisions (pouch) 3 months post operative
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Epithelialized palatal graft technique for dental implants
• Predictable success
• Versatile technique
• “Free gingival graft” : Misnomer
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Sullivan et al classified gingival grafts based on their thickness
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• Thicker grafts resist functional stresses of
mastication, intracrevicular restorative
procedures and oral hygiene procedures
better than thin grafts
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Indications and sequencing
• Absence of attached gingiva at edentulous implant
site : perform grafting 8 to 12 weeks before
implant placement
• Less than 3mm attached tissue and less than 10mm
height of mandible or maxilla
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• If adequate gingival tissue exists (3mm) at
implant site, gingival grafting can be
performed at second stage for submerged or
simultaneously with nonsubmerged implant
placement
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Contemporary surgical technique
• Recipient-site preparation
1. 1st step to minimize time
2. Outlining with 15C scalpel
3. Horizontal followed by the vertical incisions
4. Sharp dissection
5. Vestibular extension for immobilization
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• Donor-site preparation
1. Performed during preoperative examination
2. Palate (common), even edentulous sites used
3. PM – Molar region preferred
4. Tin foil – transfer of exact dimensions
5. Uniform partial thickness harvest
6. Sutured to recipient bed
7. Pressure with moistened saline gauze
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• Immobilization of the graft at recipient site
• Close adaptation and rigid immobilization
• Should form butt joint with periphery of recipient
bed to prevent sloughing
• Thin fibrin clot
• Initial nourishment of graft
• Suturing at edges coronally
• Pressure application with moist gauze for 10 mins
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• In edentulous mandible : Horizontal incision at
mucogingival junction
• Vertical incision at the midline
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Gingival grafting to establish a stable peri-implant soft tissue environment in the edentulous mandible
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Gingival grafting at second stage surgery in edentulous mandible
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Outlining and harvesting of donor tissue
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Gingival grafts have been adapted and secured at recipient site with meticulous suturing
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Four and eight weeks post operative
One year post operative
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Alloderm
• Alternative to harvesting autogenous epithelialized
palatal grafts (1996)
• Advantages
• Disadvantages
• Two distinct sides identified
• Orientation of the graft on recipient bed
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Edentulous ridge with inadequate vestibular depth and thin band of attached tissue
Alloderm in PRP solution followed by suturing at the recipient site
One week post surgery Eight weeks post surgery
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Subepithelial connective tissue graft technique for dental implants
• Langer and Calagna 1982
• New approach to anterior cosmetic enhancement
• Versatile pocedure to enhance soft tissue contours
around natural teeth and dental implants
• Open approach
• Closed approach
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• Graft harvested internally from the palate resulting
in partial thickness donor site pouch....comfortable
palatal wound
• Advantage of dual blood supply at recipient site
• Less technique sensitive
• Easier to perform
• More predictable and excellent colour match
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• Indications and sequencing in implant
therapy
• Reconstruction can be done prior to implant
placement, during osseointegration period, at
abutment connection and at any time during the
recall period
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• When a small volume defect in soft tissue contour
identified at implant site
• Most practical to perform subepithelial CT graft at
time of submerged implant placement or prior to
nonsubmerged implant placement
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• Recipient site considerations
• First step, minimizes the time between graft harvest
and transfer
• Helps determine precise dimensions of donor tissue
• Open or closed technique
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• Recipient site surgery
• Closed approach
• Horizontal incision on mesial & distal of soft
tissue defect just coronal to level of root or
abutment coverage 1mm depth
• Split-thickness dissection beyond MGJ
• Width of recipient site : 3 times that of exposed
root or abutment
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• Graft immobilization
• Dimensions should closely match the recipient
pouch
• 4-0 chromic suture : Horizontal mattress suture to
engage apical portion of pouch, engaging the graft
and exiting the pouch apically
• Sling suture for close adaptation of the graft
• Interrupted sutures to close the flap in papillary
areas
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Closed approach
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• Open approach
• Partial-thickness horizontal and vertical incisions
• Exaggerated curvilinear bevelled incisions outlined
to elevate split-thickness flap
• Goal : maximize the thickness of overlying tissue
flap leaving a thin layer of immobile periosteum
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• Graft immobilization
• Dimensions should closely match recipient site
• Sling sutures to secure the graft coronally in
position
• Also secured laterally and apically with additional
sutures
• Next, cover flap secured coronally with interrupted
sutures passing through the papillae
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Open approach
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Open recipient site Closed recipient siteEasier to perform More difficult to prepare
(blind technique)Allows direct
visualization of dissection for uniform
recipient site
Immobilization of graft is technique sensitive
Facilitates coronal advancement of cover
flap
Contraindicated when vestibular depth is
minimalUse of releasing incisions
sacrifices circulationLimits coronal advancement
May require secondary gingivoplasty
Preserves circulation to area
Superior esthetics
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• Donor site considerations
• Dimensions depend on size and shape of patient’s
palate
• Ideal location
• Dual and single incision variations are commonly
used
• Vertical incisions avoided to preserve blood supply
and avoid sloughing
• Protective palatal stent
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Donor site surgeryDual incision technique
Full thickness curvilinear incision 3mm apical to marginal gingiva
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Second, partial thickness incision 1mm deep defines thickness of donor tissue
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Tip of scalpel is reoriented to parallel the surface of palatal tissues and sharp dissection used to create a subepithelial pouch
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From within the pouch vertical incisions are made through CT and periosteum to define width of donor tissue
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Subperiosteal dissection performed using paddle end of elevator and horizontal incision made at apical extent
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Donor tissue consisting of epithelium, CT, fat and periosteum is taken to recipient site and adapted
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Collaplug absorbable collagen dressing is used to aid in hemostasis and fill the considerable dead space. Chromic gut suture (4-0) is used for closure of donor
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Single incision technique
Full thickness curvilinear incision 3mm apical to PMs
Blade reoriented to parallel the surface of the palate
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Conclusion
• This topic provides the basis for successful
application of oral soft tissue grafting in implant
therapy and a clear explanation of indications,
advantages, expected outcomes and limitations of
the most commonly used soft tissue grafting
techniques