Posted by in Blog, Featured Articles | 6 comments

At the Sclar Center for Empowered Dental Implant Learning, my students frequently ask:

How do I know when soft tissue augmentation is indicated around dental implants or at sites with deficient alveolar ridges requiring bone grafting?

How should the procedures be sequenced?

 

Soft Tissue Requirements

To begin with, implant surgeons must understand that soft tissues play an important role in the formation of a biologic  periimplant soft tissue seal and play a nutritive role for underlying periimplant bone. Numerous studies demonstrate that periimplant soft tissue dimensions of 3.0 mm vertical tissue height and 2.0-3.0 mm tissue thickness are necessary in order to satisfy the vertical and lateral biologic width requirements at an implant site.

In addition, numerous studies demonstrate that when the periimplant soft tissues dimensions are less than those described above, the biologic width phenomenon will establish a periimplant soft tissue seal at the expense of approximately 1.0-2.0 mm of periimplant crestal bone height, resulting in apical migration of the soft tissue seal, which is often responsible for the exposure or visualization of metal implant components.

Methodical periimplant soft tissue flap design, as well as use of site specific periimplant soft tissue procedures, such as the papilla regeneration maneuver, are often required for circumferential adaptation of optimal dimensions of periimplant soft tissues. Nevertheless, when soft tissue dimensions are inadequate for the biologic requirements, periimplant soft tissue augmentation is indicated.

Greater Requirements at Esthetic Implant Sites

The soft tissue requirements at esthetic implant sites are often greater. The goal at esthetic sites is to create a natural appearing implant restoration that includes:

    • Harmonious facial-gingival margin position,
    • Gingival zenith,
    • Tissue color and texture, and
    • A congruent mucogingival junction position.

 Key Points to Remember

Approximately 3.0 mm width of good quality, preferably keratinized periimplant soft tissue with a thickness of about 2.0 mm will provide for a stable periimplant soft tissue seal that protects the underlying periimplant bone levels, favoring long term success of the implant restorations(s).

Whenever the soft tissue dimensions are less than the above, periimplant soft tissue grafting is indicated for long term functional success.

Esthetic sites have greater soft tissue volume requirements.

 

Timing and Sequencing

There are many factors that influence the timing and sequence of periimplant soft tissue augmentation procedures including:

    • Operator experience,
    • Gingival biotype,
    • Presence or absence of keratinized tissue at the site,
    • Presence or absence of tissue scarring or adhesions at the site,
    • Presence or absence of chronic inflammation at the site or adjacent sites,
    • Adequate donor sites,
    • Use of a submerged or non-submerged implant approach, and
    • Level of esthetic concern expressed by the patient.

 

Procedure Selection

Sites with Adequate Width of Keratinized Tissue and Inadequate Soft Tissue Thickness

The most straightforward situation is an adequate width of keratinized tissue at the site but inadequate soft tissue thickness. Typically this is treated with a subepithelial connective tissue graft harvested from the palate or maxillary tuberosity, performed prior to or simultaneous with implant placement according to the operator’s experience.

Sites with Inadequate Soft Tissue Cover and Laterally Deficient Alveolar Ridge Defects

Sites with inadequate soft tissue cover and laterally deficient alveolar ridge defects can be treated by clinicians with advanced experience doing simultaneous hard and soft tissue tissue augmentation, using supported membrane GBR procedures and block bone grafts with subepithelial connective tissue grafts, as long as the soft tissue cover is free from scarring, adhesions or chronic inflammation. Alternatively, less experienced clinicians can stage the procedures with soft tissue grafting preceding the bone graft by at least three months.

Sites with Inadequate Soft Tissue Cover and Vertically Deficient Alveolar Ridge Defects

Sites with inadequate soft tissue cover and vertically deficient alveolar ridge defects can be treated by clinicians with advanced experience doing simultaneous hard and soft tissue tissue augmentation, using supported membrane GBR procedures and block bone grafts with subepithelial connective tissue grafts, as long as the soft tissue cover is free from scarring, adhesions or chronic inflammation. These cases require considerable operator experience.

Sites Lacking Keratinized Tissue

Case scenarios that lack any keratinized tissue at the implant sites are more challenging. These cases are typically treated using a gingival graft or a combination onlay-interpositional graft performed prior to implant placement or bone grafting. Nevertheless, operators with advanced experience typically can perform gingival and/or combination onlay-interpositional grafts simultaneously with implant placement. The presence of keratinized tissue and an adequate soft tissue envelope is required to avoid subsequent bone graft complications as the soft tissue cover contributes to successful incorporation and maintenance of the bone graft volume by providing tissue cover, vascularization and a mesenchymal cell pool required for phase II remodeling of the graft.

 Sites with Compromised Vitality

Typically, sites with compromised vitality due to trauma, tooth avulsion with re-implantation, numerous endodontic procedures and past infections, and/or the presence of thin tissues with scarring and adhesions are best treated with a staged approach starting with soft tissue site development by surgeons with advanced knowledge, skill and experience.

 

ISTM 2013 is around the corner!

Please join me at ISTM 2013, my 15th annual comprehensive dental implant surgery training course at the Miami Beach Resort and Spa, February 1-5, 2013. 
 
Call 305-913-2467 for EXCLUSIVE TUITION for Facebook and LinkedIn Connections.
 
ISTM 2013 is a flexible program. You can choose the days you will attend the general sessions, and you can select optional workshops.
 
To download the ISTM 2013 brochure and see all five days of the program, click here.

 

 

 

6 Comments

  1. April 20, 2013

    Thanks for the excellent post!

  2. May 4, 2013

    Everyone should know this. Not only the surgeon but also the patient should be informed about the use of this tissue. Thanks for sharing this information. Dental Surgery

  3. June 21, 2013

    The etiology, or cause, of plaque-induced gingivitis is bacterial plaque, which acts to initiate the body’s host response. This, in turn, can lead to destruction of the gingival tissues, which may progress to destruction of the periodontal attachment apparatus.^`,”

    Best wishes http://healthmedicine101.comzu

  4. July 17, 2013

    There are so many things which are related to Dental Implants , one of which is soft tissue agumentation. After reading this post, I have gotten to know about its importance, how aumentation works to seal the tissue and at the same time give support to the mouth for underlying periimplant bone. Here, everything is so well discussed that anyone can easily get the idea. Thanks for sharing this nice post with us.

  5. September 18, 2013

    Thanks for sharing the information .I like to know the method and the site especially in palate as a donor for soft tissue grafting ..and is the healing of donor site is un eventful and painless…pl.through soMe light..thanks

  6. July 16, 2014

    I am a dental practitioner and I am the big follower of this blog. I always enjoy reading your articles. Dental implants have evolved dramatically over the last decade. The augmentation of the soft tissue around dental implants has emerged as an area of much concern and focus. Thanks for sharing this useful article. All the best!! :)

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