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. 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
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. 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. 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. • 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. 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. • 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. 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. • 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. • 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.
21.
22. 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
23. • 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
24. 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
25. CT pedicle is elevated
CT pedicle is rolled &
secured in buccal pouch
Performed simultaneous with
nonsubmerged implant placement
26. Premolar implant site with soft tissue defect on buccal aspect
Elevation of split thickness palatal flap CT pedicle elevated with Adsons forceps
27. 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
30. Sullivan et al classified gingival grafts based on
their thickness
31. • Thicker grafts resist functional stresses of
mastication, intracrevicular restorative
procedures and oral hygiene procedures
better than thin grafts
32. 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
33. • 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
34. 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
35. • 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
36. • 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
37. • In edentulous mandible : Horizontal incision at
mucogingival junction
• Vertical incision at the midline
38.
39.
40. Gingival grafting to establish a stable peri-implant soft tissue
environment in the edentulous mandible
43. Gingival grafts have been adapted and secured at
recipient site with meticulous suturing
44. Four and eight weeks post operative
One year post operative
45. Alloderm
• Alternative to harvesting autogenous epithelialized
palatal grafts (1996)
• Advantages
• Disadvantages
• Two distinct sides identified
• Orientation of the graft on recipient bed
46. 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
47. 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
48. • 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
49. • 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
50. • 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
51.
52.
53. • Recipient site considerations
• First step, minimizes the time between graft harvest
and transfer
• Helps determine precise dimensions of donor tissue
• Open or closed technique
54. • 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
55. • 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
57. • 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
58. • 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
60. 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
61. • 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
62. Donor site surgery
Dual incision technique
Full thickness curvilinear incision 3mm apical to marginal gingiva
67. Donor tissue consisting of epithelium, CT, fat and periosteum
is taken to recipient site and adapted
68. 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
69. Single incision technique
Full thickness curvilinear incision
3mm apical to PMs
Blade reoriented to parallel the
surface of the palate
70. 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
Hinweis der Redaktion
Not only hard tissue integration but soft tissue biologic seal as well as seen around natural dentition in terms of periodontium
Importance of soft tissue seal : bacterial and mechanical challenges
To be clinically successful : integration with CT and epithelium important
Soft tissue integration : describes the biologic processes during formation and maturation of structural relationship bet soft tissues and transmucosal portion of implant
Maintenance of healthy soft tissue barrier is as imp as osseointegration for long term success of implant supported prosthesis
Oral Epithelium (OE) is a layer of stratified squamous keratinized epithelium, which faces the oral cavity. The boundary between the OE and the underlying connective tissue (CT) has a wavy course. The CT portions which projects into the epithelium are called connective tissue papillae (CTP), and are separated from each other by epithelial ridges (ER), which are also called rete pegs.
Oral Sulcular Epithelium (OSE), like the words, is the part of OE on the top of the sulcus. Also, is a stratified squamous epithelium. However, this layer is non-keratinized or parakeratinized. The OSE is continuous with the OE and lines the lateral surface of the gingival sulcus (GS).
Both OE and OSE shares many of the characteristics such as, good resistance to mechanical forces and relative impermeability to fluid and cells.
Junctional Epithelium (JE), a non differentiated, stratified squamous and non-keratinized epithelium with a very high rate of cell turnover. It forms a collar around the cervical portion of the tooth that follows the CEJ. The free surface of this collar constitutes the floor of the gingival sulcus. The JE is widest in its coronal portion (15-20 cell layers), but becomes thinner (3-4 cell layers) towards the CEJ. (healthy condition) It is assumed that JE is a key role in maintenance of periodontal health, it produces the epithelial attachement and therefore created the firm connection of soft tissue to the tooth surface.
About Epithelial attachment, is the cell layer facing the tooth providing the actual attachment of the gingiva to the tooth surface by means of structural complex. Each JE cell adjacent to the tooth forms hemidesmosomes that enable this cells to attach to the surface of the internal basal lamina (IBL) and ultimately to the surface of the tooth. The other side is the external basal lamina (EBL) and to the CT.
To differentiate between the OE, OSE, and JE, the size of the cells in the JE is larger than in the OE. The intercellular space in the JE, which is, relative to the tissue volume, comparatively wider than the ones in the OE. And last, the number of desmosomes in JE is smaller than the ones in the OE. The point is, hemidesmosomes are specialized in junctional complexes, contributing to the attachment of epithelial cells to the underlying basement membrane.
Differences between periodontal and peri-implant soft tissues
The differences render the implant more susceptible to mechanical and bacterial challenges
Lack of consensus
Stable peri implant mucosa is one which provides transmucosal seal against bacterial irritants and structural stability to withstand mechanical trauma
Attached non mobile tissues around implants resist discruption of JE seal and limit apical spread of marginal inflammation preventing soft tissue and bone loss
Therefore need to rely on clinical findings than expirimental studies
Rationale
Helps Restorative dentist with prosthetic friendly environment
Abutment connection and impression procedures
Evolution of implant design from two piece to one piece lead to non submerged techniques
Advantages
Provides sufficient time for mature soft tissue integration prior to initiation of restorative process
This helps stabilize JE and sulcus depth during hard and soft tissue integration
Eliminates the need of abutment connection procedures or soft tissue refinements thereby providing prosthetic friendly environment
Due to few surgical procedures, circulation to the area is preserved
Treatment time and pt discomfort reduced and pt acceptance improved
Peri-implant plastic surgery aims at improving the esthetic aspects of smile appearance and masticatory function. Enhancement of the esthetic appearance can lend significant support to patients wishing to experience more effective and successful interactions
with others in personal, social and workplace situations.
Definition
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.
The rationale for the peri-implant plastic surgery approach goes well beyond pure esthetics to address issues of quality-of-life and the psychosocial wellbeing of patients. Peri-implant plastic surgery is also important for creating peri-implant keratinized mucosa and interimplant soft tissue height in order to avoid food impaction, interimplant airflow and speech problems.
In addition to these instruments, periosteal chisels and files should be included as part of the implant soft tissue armamentarium since osseous modifications are often indicated around implants or adjacent dentition to create a positive architecture in support of esthetic soft tissue drape. Rotary instruments and absorbable suture materials are also useful.
Facilitate elevation, retraction, repositioning and tension free closure
Rationale for soft tissue grafting should be based on clinical experience rather than experimental or clinical studies
Functional or aesthetic concerns – placement of restorative margins below the gingival margin
Mechanical challenges – tooth preparation, soft tissue retraction and impression procedures, Cementation of provisional and permanent restorations, removal of implant healing abutments and their replacement with permanent abutments, implant level impressions and so on
Although implant therapy can be successful in areas of alveolar mucosa, restorations are far more predictable when an adequate zone of attached tissue exists. When one considers that periodontal attachment apparatus is mechanically superior to the protective soft tissue seal formed around an implant, it seems reasonable that the dimensions of gingival tissue surrounding an implant resto should be equal to or greater than 5mm. When implant therapy is planned in the non esthetic areas, author refers to conclusions of lang n loe that a zone of 2mm of attached gingiva around natural dentition is enough to maintain health of marginal tissues. And 3mm for dental implants.
1st day
- Connective tissue becomes oedematous, disorganized & undergoes lysis degeneration of some of its elements
- Transudate from the host vessels provides initial nutrition & hydration for
the initial survival of the graft(plasmatic circulation)
2 – 4 days
Revascularization by the capillaries from the recipient bed proliferates into the graft to form a network of new capillaries & anastomose with preexisting vessels
Epithelium undergoes degeneration . a thin layer of new epithelium is present by the 4th day
Fibrous organization of the interface between the graft & the recipient bed
2 – 3 weeks
-Functional integration of the graft occurs by the 17 th day although it is still morphologically distinguishable from the surrounding tissue for months
The graft eventually blends with the adjacent tissues
Complete healing by 10 ½ weeks
Versatile because it increases width and covers the denuded root or the implant abutment
Thick grafts : resist functional stresses better than thin grafts
Early revascularization of graft is not v predictable but superior results are obtained when these are used for root or abutment coverage
In certain instances when there is severe ridge atrophy the resultant sharp dissected flap can be sutured at the base of the recipient site with sutures
Irregular graft or recipient site surface allows pooling of blood between host bed and graft thereby limiting both early diffusion of nutrients to graft and extension of capillaries into it.mobility of graft has same deleterious effects.
Any existing gingival tissues are repositioned lingually or palatally to the implants. Split thickness dissection is carried out apically to create uniform periosteal site. Care needs to be taken to avoid damage to mental nerve with vertical releasing incisions. Therefore a midline vertical releasing incision and sharp dissection to create an adequate recipient site >5mm apicocoronal is made. Mucosal flaps or tissue excised and sometimes sutured at the base in case of severe atrophied mandibles
Freeze dried allograft skin processed to remove all immunogenic cellular components (epidermis and dermal cells) leaving a useful acellular dermal matrix for soft tissue augmentation.
Surgical technique is same as gingival graft. Graft must be rehydrated 10mins before use. Connective tissue side and basement membrane.CT side contains pre existing vascular channels for cell infiltration and revascularization.
Basement membrane side facilitates epithelial cell migration and attachment
Larger grafts preferred due to greater secondary shrinkage
Comination with PRP helps better incorporation of the graft
Advantages
Dual blood supply at recipient site
Less invasive donor site wound
Superior color match
Technically less demanding
Not dependent on smooth palatal surface for success
Tremendously versatile (for root /abutment coverage and to increase the width of attached gingiva)
Grafting prior facilitates reconstruction of missing soft tissue volume in the area critical for esthetic restorative emergence, because a large recipient site can be developed to include periosteal blood supply on both the buccal and palatal aspects of the alveolar ridge. This recipient site design is ideal to support graft vascularization in the area critical for eventual prosthetic emergence.
Once an abutment is connected to a submerged implant or when a non submerged implant is placed, the recipient bed can be developed only on buccal aspect of the emerging implant, thus limiting the peripheral blood supply availabel to sustain the graft in the area critical for prosthetic emergence.
Soft tissue contours certainly can be improved aft the implant has emerged, but reconstruction of deficient contours in the area critical for esthetic restorative emergence may not be as predictable. Therefore the author prefers to use a coronally advanced flap augmented by CT when grafting at the same time as abutment connection or nonsubmerged implant placement. Adequate vestibular depth is necessary to allow flap elasticity for advancement.
Curvilinear bevelled flap design in open technique allows greater coronal flap advancement and also increases size of recipient site and peripheral blood supply as well.
Avoid tearing of the pouch
Instrument used to check the resultant pouch and confirm that dissection is complete
Any tissue strands need to be checked within the pouch extending from periosteum to
the overlying soft tissue which will prevent proper positioning of the CT graft within the pouch
Afetr measuring the dimensions of recipient pouch with a periodontal probe the dimensions
are transferred to harvest the tissue from donor site.
When a closed recipient used, the dimensions of donor CT should closely match those of recipient pouch
Periosteal side of the graft should face down at the recipient site
Mattress suture gently pulls the graft into recipient pouch to secure it thereby resisting coronal displacement
Sling suture invloving the graft ant the interproximal tissue
Atleast 2/3rd or more of graft should be secured within the pouch
When coronal advancement of cover flap will be performed, the adjacent papillary areas are de-epithelialized. Dimensions of recipient are then measured with probe and hemostasis achieved
However it is helpful if donor tissue is trimmed to be slightly smaller than the open recipient site
Shallow palate may limit the dimensions in terms of apical extent due to presence of neurovascular bundles
Dual technique : easier to perform
Graft thickness defined by the second partial thickness incision thereby ensuring uniform thickness of donor tissue obtained
Protective palatal stent post operatively to reduce pain
Author prefers to harvest underlying palatal periosteum with CT to improve the periosteal vascular network for potential anastomotic connections during graft vascularization
Maxillary tuberosity is another potential donor site for subepithelial CT graft