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Soft tissue grafting around implants

soft tissue grafts

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Soft tissue grafting around implants

  2. 2. 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
  3. 3. 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
  4. 4. • Connective tissue attachment above the alveolar crest 1. Transseptal fibers 2. Dentogingival/dentoperiosteal fibers 3. Circular fibers
  5. 5. • Epithelial tissue attachment 1. Oral epithelium 2. Sulcular epithelium 3. Junctional epithelium • Vascular supply
  6. 6. • 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
  8. 8. Comparison of the interface
  9. 9. Difference in vascular supply
  10. 10. PERMUCOSAL SEAL Choosing between a submerged and nonsubmerged approach
  11. 11. 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.
  12. 12. 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
  13. 13. 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
  14. 14. • 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
  15. 15. 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
  16. 16. • 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
  17. 17. 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
  18. 18. • 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
  19. 19. • 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
  20. 20. 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
  21. 21. • 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
  22. 22. 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
  23. 23. CT pedicle is elevated CT pedicle is rolled & secured in buccal pouch Performed simultaneous with nonsubmerged implant placement
  24. 24. Premolar implant site with soft tissue defect on buccal aspect Elevation of split thickness palatal flap CT pedicle elevated with Adsons forceps
  25. 25. 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
  26. 26. Epithelialized palatal graft technique for dental implants • Predictable success • Versatile technique • “Free gingival graft” : Misnomer
  27. 27. Sullivan et al classified gingival grafts based on their thickness
  28. 28. • Thicker grafts resist functional stresses of mastication, intracrevicular restorative procedures and oral hygiene procedures better than thin grafts
  29. 29. 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
  30. 30. • 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
  31. 31. 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
  32. 32. • 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
  33. 33. • 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
  34. 34. • In edentulous mandible : Horizontal incision at mucogingival junction • Vertical incision at the midline
  35. 35. Gingival grafting to establish a stable peri-implant soft tissue environment in the edentulous mandible
  36. 36. Gingival grafting at second stage surgery in edentulous mandible
  37. 37. Outlining and harvesting of donor tissue
  38. 38. Gingival grafts have been adapted and secured at recipient site with meticulous suturing
  39. 39. Four and eight weeks post operative One year post operative
  40. 40. Alloderm • Alternative to harvesting autogenous epithelialized palatal grafts (1996) • Advantages • Disadvantages • Two distinct sides identified • Orientation of the graft on recipient bed
  41. 41. 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
  42. 42. 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
  43. 43. • 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
  44. 44. • 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
  45. 45. • 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
  46. 46. • Recipient site considerations • First step, minimizes the time between graft harvest and transfer • Helps determine precise dimensions of donor tissue • Open or closed technique
  47. 47. • 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
  48. 48. • 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
  49. 49. Closed approach
  50. 50. • 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
  51. 51. • 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
  52. 52. Open approach
  53. 53. Open recipient site Closed recipient site Easier 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 minimal Use of releasing incisions sacrifices circulation Limits coronal advancement May require secondary gingivoplasty Preserves circulation to area Superior esthetics
  54. 54. • 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
  55. 55. Donor site surgery Dual incision technique Full thickness curvilinear incision 3mm apical to marginal gingiva
  56. 56. Second, partial thickness incision 1mm deep defines thickness of donor tissue
  57. 57. Tip of scalpel is reoriented to parallel the surface of palatal tissues and sharp dissection used to create a subepithelial pouch
  58. 58. From within the pouch vertical incisions are made through CT and periosteum to define width of donor tissue
  59. 59. Subperiosteal dissection performed using paddle end of elevator and horizontal incision made at apical extent
  60. 60. Donor tissue consisting of epithelium, CT, fat and periosteum is taken to recipient site and adapted
  61. 61. 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
  62. 62. Single incision technique Full thickness curvilinear incision 3mm apical to PMs Blade reoriented to parallel the surface of the palate
  63. 63. 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

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