Implant Dentistry - Soft Tissue Procedures

Implant Dentistry – Soft Tissue Procedures – Presentation Transcript

• 1. 19. Soft Tissue Procedures Moustafa H El-Ghareeb BDS MS The Surgical Implant Center UCLA School of Dentistry This program of instruction is protected by copyright ©. No portion of this program of instruction may be reproduced, recorded or transferred by any means electronic, digital, photographic, mechanical etc., or by any information storage or retrieval system, without prior permission.
• 2. 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 Sclar AG, 2003 implant ! Absence of periodontal ligament blood supply
• 3. Clinical Exam The systematic evaluation of the esthetic implant patient starts with assessment of the underlying hard tissue 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 Crestal Bone Buser D, 2004 Facial bone wall
• 4. 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
• 5. Clinical Exam Number of teeth visible during smiling ! 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)
• 6. Clinical Exam Partially Edentulous 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 (MericskeStern 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
• 7. Clinical Exam Gingival biotype: Thick blunted: ü  Resists recession & reacts to surgical & restorative insults with pocket formation Thin scalloped: Thick Blunted 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 Thin Scalloped
• 8. Clinical Exam Gingival margin/outline: •  Sinuous versus Straight pattern Sinuous pattern straight gingival pattern •  Symmetry, asymmetry distracts from the esthetic appearance of the patient’s smile Discrepancy in gingival margin positions
• 9. Clinical Exam Interdental papilla evaluation: Palacci classification (Palacci 2001 ! 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): Palacci 2001 I II •  4=papilla fills the entire interdental space •  3=>50% of the space filled •  2=<50% of the space filled •  1=no papilla present III IV
• 10. 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)
• 11. Soft Tissue Surgical Procedures At Time of Second Stage Surgery ! ! ü  ü  ü  ü  ü  ü  Assess amount of keratinized mucosa and proceed accordingly Different techniques in different situations: Tissue punch or Scalloping Midcrestal incision Crestal incision but more palatal Full thickness flap Partial thickness flap with apical repositioning Pedicle rotational flaps (papilla regeneration)
• 12. Soft Tissue Surgical Procedures At Time of Second Stage Surgery 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
• 13. Soft Tissue Surgical Procedures At Time of Second Stage Surgery ST punch cannot be used with limited amount of keratinized mucosa
• 14. Soft Tissue Surgical Procedures At Time of Second Stage Surgery ST punch & scalloping techniques Scalloping technique Soft-tissue punch Punch & scalloping technique
• 15. Soft Tissue Surgical Procedures At Time of Second Stage Surgery Full thickness flap technique Reverse soft-tissue architecture Full-thickness flap technique Full-thickness flap technique H incision (full thickness flap)
• 16. Soft Tissue Surgical Procedures At Time of Second Stage Surgery Palacci papilla regeneration technique Palacci 2001 Can be performed only when adequate amount of keratinized mucosa is available Palacci double pedicle flaps
• 17. Soft Tissue Surgical Procedures At Time of Second Stage Surgery Palacci papilla regeneration technique Semi-lunar bevel incision Pedicle flaps Rotation of pedicle flaps Palacci, 2001
• 18. Soft Tissue Surgical Procedures At Time of Second Stage Surgery Partial thickness flap with apical repositioning: ! 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 Narrow zone of keratinized mucosa Sharp supra-periosteal dissection Partial thickness flap Is apically repositioned & sutured to periosteum
• 19. Soft Tissue Surgical Procedures Free palatal & CT grafts Preparation of recipient site: Management of donor tissue: 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 ! ! ! ! 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
• 20. Soft Tissue Surgical Procedures 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
• 21. Soft Tissue Surgical Procedures Free palatal Grafts (free gingival grafts): ! Donor tissue is sized to recipientsite 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.
• 22. 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
• 23. Soft Tissue Surgical Procedures Free palatal graft Atrophic MN with thin band of attached ST Immobilization of graft at recipient site Creation of a uniform periosteal recipient site One week postoperative: Superficial epithelial sloughing & initial revascularization One-year postoperative view Note secondary contraction (arrow)
• 24. Soft Tissue Surgical Procedures 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
• 25. Soft Tissue Surgical Procedures 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
• 26. 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) 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 Tunneling technique
• 27. 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