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Soft tissue grafting around implants
- 1. SOFT TISSUE ANATOMY & GRAFTING PROCEDURS AROUND DENTAL IMPLANTS
- 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
- 4. • Connective tissue attachment above the alveolar crest 1. Transseptal fibers 2. Dentogingival/dentoperiosteal fibers 3. Circular fibers
- 5. • Epithelial tissue attachment 1. Oral epithelium 2. Sulcular epithelium 3. Junctional epithelium • Vascular supply
- 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
- 7. NEED & RATIONALE FOR ATTACHED PERI-IMPLANT SOFT TISSUES
- 8. Comparison of the interface
- 9. Difference in vascular supply
- 10. PERMUCOSAL SEAL Choosing between a submerged and nonsubmerged approach
- 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
- 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
- 29. Epithelialized palatal graft technique for dental implants • Predictable success • Versatile technique • “Free gingival graft” : Misnomer
- 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
- 40. Gingival grafting to establish a stable peri-implant soft tissue environment in the edentulous mandible
- 41. Gingival grafting at second stage surgery in edentulous mandible
- 42. Outlining and harvesting of donor tissue
- 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
- 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
- 56. Closed approach
- 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
- 59. Open approach
- 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
- 63. Second, partial thickness incision 1mm deep defines thickness of donor tissue
- 64. Tip of scalpel is reoriented to parallel the surface of palatal tissues and sharp dissection used to create a subepithelial pouch
- 65. From within the pouch vertical incisions are made through CT and periosteum to define width of donor tissue
- 66. Subperiosteal dissection performed using paddle end of elevator and horizontal incision made at apical extent
- 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
Editor's Notes
- 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