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  • 1. 80Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012 Management Of Soft Tissue Esthetics In Implant Dentistry Dr. Ajay Vikram Singh Dr. Ajay Vikram Singh, after completing his BDS, received PG certificate training in Implantology from India followed by advanced level implant training at different centers and continuing education implant programmes in USA. He is an internationally acclaimed mentor, speaker and researcher in the field of implantology. He has spoken as the key note speaker in different national and international implant conferences. Besides being an active member of many prestigious implant associations, he is a Fellow and Diplomate of International Congress of Implantology. He has been running basic to advanced level implant training programmes at his Implant Center, at Agra since 2005 and has trained many national as well as international dentists with his implant skills. Dr. Ajay can be reached at – drajaydentalclinic@gmail.com Dr. Sunita Singh Dr. Sunita Singh, after completing her BDS received a lot of continuing her education in Esthetic And Implant Dentistry and Fixed Orthodontics at different Centers in India and USA. She has attended and presented her skills in many national and international Dental Conferences. She has taken special training in Cosmetic Dentistry at the Continuing Education Programme at Washington University (USA). She is a member of American College of Prosthodontists in USA. She is an active member of Indian Academy of Aesthetic and Cosmetic Dentistry as well as Academy of Oral Implantology. She has been practicing with Dr. Ajay since 2003 at Dr. Ajay Dental Clinic and Research Center, Agra. Introduction The successful use of dental implants to replace missing teeth has been one of the most popular, exciting and evolving areas of clinical dentistry. When implants are thought as a treatment option, treatment planning has become more complex for the dental practitioner and an interdisciplinary team approach is recommended to achieve a long term esthetic as well as functional outcome in the implant restorations. Failure to demonstrate such an approach might lead to undesirable esthetic and functional implant complications. The long term clinical and esthetic success of an implant retained restoration is determined by stable peri-implant soft tissue morphology in hormone with the surrounding soft tissues and natural dentition. In addition to successful osseointegration of the implant, the surrounding soft tissues play an important role in the vascularization of the underlying bone. Insufficient soft tissue causes improper nutrient supply the underlying peri-implant bone and may lead to crestal bone resorption after implant is restored in function. Proper gingival architecture is especially important in the implants placed in the esthetic region. Thorough treatment planning and knowledge of the specific phases of inflammatory and regenerative processes associated with wound healing are essential for predictable esthetic results. Preoperative deficiency of the soft tissue often mandates the extensive soft tissue management, mobilization and augmentation procedures to obtain the esthetics around the implant restorations. Various soft tissue management and augmentation techniques are applied to obtain adequate esthetic emergence profile of the implant restoration with sufficient keratinized gingiva. However, efforts should be made to preserve the existing esthetic soft tissue profile by implant placement with minimal soft tissue injury during implant insertion and uncovering and also by supporting the soft tissue architecture using a provisional prosthesis during subgingival or open healing of the implant. Immediate implantation in the extraction socket with an anatomical provisional restoration, which is immediately fixed after the implant insertion to support the soft tissue profile of the socket, should be practiced in the esthetic region. Optimizing implant placement, particularly position and angulation, allows the clinician not only to approximate the form of the original dentition, but to create an esthetic soft-tissue contour and provide a long-term function. • Favorable and unfavorable soft tissues around the implant The keratinized and stable soft tissue with thick biotype is the favorable tissue for long term implant health as it is more resistant to chemical and mechanical injuries, muscle pull, etc. (Fig. 1) and thus prevent the occurrence of peri-implantitis and Fig. 1 Thin, non keratinized and mobile marginal soft tissue is less resistant to the muscle pull and recedes, which may result in recurrent peri-implantitis and subsequent peri-implant crestal bone loss.
  • 2. 82Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012 crestal bone loss. In short, for the long term health of the implant restoration minimum 2-3 mm of thick, keratinized and attached marginal soft tissue should be present. Efforts should be made to preserve the existing keratinized tissue at the implant site by closely evaluating the type of soft tissue biotype and accordingly planning the incisions and implant placement protocols to minimise the loss or recession of the favorable marginal soft tissue. A thick, keratinized and non mobile marginal soft tissue offers several advantages such as protect the peri-implant tissues from injury and infection, resist the pull of muscles, resistant to the marginal soft tissue recession, better plaque control, adequate soft tissue esthetics, etc. (Fig. 2) Soft Tissue Biotypes Gingival thickness, its morphology, presence of interdental papilla and the osseous architecture at the site are all determining factors in periodontal biotyping and can influence surgical approaches and healing in the field of implantology. Ochsenbein & Ross described healthy periodontal tissues by the biotype categories of thin scalloped (thin gingival tissue, long papillae and thin scalloped bone) and thick flat (thick gingival tissue, short and wide papillae and thick, flat bone). Olsson & Lindhe further categorized the periodontium based on the associated tooth form and susceptibility to gingival recession. The triangular tooth form is associated with a scalloped and thin periodontium. The contact area for the triangular tooth shape is at the coronal third of the crown, supporting a long and thin papilla. The squared tooth combines with a thick and flat periodontium. The contact area for the square tooth shape is at the middle third of the crown, supporting a short and wide papilla. Periodontal biotyping affects practically all periodontal surgical procedures, including crown lengthening, implant placement and tissue grafting. A thin periodontal biotype is the more technique-sensitive and can post-treatment, give rise to gingival recession or black triangle formation. An implant placed in a site with a thin periodontal biotype may develop mucosal recession or bluish color changes. Soft Tissue Management Peri-implant mucosal height essentially follows the crest of the alveolar bone; however, the determining factors in inter implant papilla development are complex and may not be fully controlled by implant design features or surgical interventions. Although bone height and thickness are major determinants of soft tissue height, factors such as tooth morphology, location of the interdental contact point and arrangement and quality of soft tissue fibers can also influence soft tissue appearance. Lack of dento-gingivo-alveolar circular, semicircular, transeptal, interpapillary and intergingival fibers around implants constitutes a major obstacle in soft tissue appearance and management around implants. The absence of inter implant papillae causing an inter-implant black triangle continues to be a significant problem in dental implant esthetics. The type of provisional prosthesis used during the healing period is critical for optimal healing. The design of the provisional restoration should be based on thorough diagnostic information and provide minimal post surgical irritation and pressure on soft tissues. A proper interim prosthesis can provide valuable suggestions about the esthetic appearance of the definitive restoration. The thickness, height and contour of the facial alveolar plate can significantly affect the labial position, the facial expression and the smile. There is a wide range of variation in the morphology of the alveolar plate. A dynamic balance between functional forces and existing alveolar bone shape sculpts the alveolar bone morphology. The housing of a standard 3.75–4mm diameter implant requires 6 mm of bone in the bucco–lingual dimension and 5–6 mm of bone in the mesio–distal dimension. Both thickness and height of the facial alveolar plate are influenced by implant angulation. A lingual implant inclination is associated with a thick and flat facial alveolar bone that provides soft tissue support in a more coronal position than normal. A labial implant inclination is associated with a thin and scalloped facial alveolar bone that often is located in an apical position. Lingually inclined anterior implants provide a thicker coronal portion of the facial alveolar plate and counteract a tendency to peri-implant bone resorption. Vertical and horizontal enlargements of the facial alveolar plate prior to implant placement can be critical for the long-term maintenance of soft tissue height. Limitations in bone quantity in the mesio–distal dimension may be caused by root position of adjacent. Tooth morphology is related to the periodontal biotype and this phenomenon is most evident in the anterior esthetic zone of the mouth. The triangular shaped tooth is linked to a thin, scalloped periodontium (Biotype I). In this biotype, the interproximal contact area is located in the coronal one-third of the crown and is associated with a long and thin papilla. The square- shaped tooth is connected to a thick and flat periodontium (Biotype II). The interproximal contact area is located at the middle one-third of the crown and supports a short, wide papilla of teeth. Orthodontic movement used to change the root position can provide the necessary space for implant insertion. A reduced horizontal distance between a tooth and a neighboring implant may adversely affect the bone level at the tooth side. Fig. 2 A thick, keratinized and stable marginal soft tissue offers several advantages such as protect the peri-implant tissues from injury and infection, resist the pull of muscles, resistant to the marginal soft tissue recession, better plaque control, adequate soft tissue esthetics, etc.
  • 3. 84Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012 Case Report - 1 Soft Tissue Preservation In Case Of Immediate Implantation In Esthetic Region Immediate implantation cases have been and continue to be the challenge in providing immediate and long term esthetic and functional implant restorations. The conventional delayed implant placement may result in loss of hard and soft tissue architectures of the socket as part of natural healing processes. The unsupported papillae get lost during the healing phase of the socket and often result in flat soft tissue at the ridge crest and black triangles around the implant prosthesis. Immediate implantation with immediate restoration supports the present soft tissue architecture and also guides the soft tissue to take a desired shape to provide final restoration with esthetic emergence. But immediate implantation with immediate functional or nonfunctional restoration is a technique sensitive procedure as it needs the implant positioning at the ideal place in the socket, achieving initial stability of the inserted implant which is adequate for immediate restoration, grafting of peri- implant socket spaces and immediate fabrication and placement of a provisional restoration of the desired anatomic shape (Figs. 3 to 8). Fig. 3 A 40 year male patient presented with mobile tooth no. 21. (a) The dental radiograph revealed the root fracture with some amount of vertical bone resorption (b) For minimal invasive flapless implant placement, the site is planned with CT cross section to place the implant at the ideal position and axis (c) The longest possible implant with its placement slightly towards palatal position to provide room for the regeneration of thick volume of hard and soft tissue on the facial aspect and to stabilize the implant in the high density nasal floor to achieve adequate primary stability so that the implant can immediately be restored, was planned. Fig. 4 The tooth and its fractured root are extracted out using periotomes and luxators with minimal trauma to the bone and soft tissue (a). The osseous topography was evaluated, all the granulation tissue was currated out of the socket and socket is disinfected using clindamycin to kill residual pathogens. The root dimensions are measured using calipers to decide the appropriate implant size. The implant osteotomy is prepared into the socket, slightly palatal to the long axis of the socket using side cutting Lindemann drills (b) An implant with dimensions of 4.2 X 16 is placed at the correct three dimensional position (c&d)The implant apex is stabilized in the high density nasal floor to achieve adequate bone implant contact percentage and primary stability (more than 35Ncm) of the implant. The implant platform is placed 2-3 mm apical to the cemento-enamel junction of the adjacent teeth and palatal to the imaginary line joining the facial aspects of the CEJ of two adjacent teeth. This provides adequate amount of tissue for esthetic emergence of the implant prosthesis. Fig. 5 The periimplant socket spaces are grafted using a mixture of HA (70%) and ß Tcp (30%) bone substitute without using any barrier membrane (a). An appropriate abutment is selected, prepared and composite is build up over its surface in the anatomical shape of natural tooth at cervical part to provide adequate support to the marginal soft tissue and papillae and also to prevent the loss of graft from the site (b). The abutment is screwed onto the implant (c).
  • 4. 86Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012 Fig. 6 A provisional prosthesis is fabricated onto this abutment in mouth using custom poly crown. A screw hole is prepared through the crown to access the connection screw (a). The provisional crown along with abutment is removed from the implant and screwed to the analog to shape the provisional crown (b and c). Fig. 7 (b). At this stage transferring the same soft tissue profile from the mouth to the working cast with the implant impression is paramount to fabricate the final crown with same anatomic shape at the cervical half. Thus the closed tray impression transfer abutment is inserted over the implants and simultaneously the soft tissue socket spaces are filled with flow composite (c). The impression is made using a silicon material and this impression abutment along with composite remain bonded to it is transferred to the impression with same orientation, which results is the transfer of the exactly same soft tissue profile to the working cast. This helps the technician to understand the anatomical shape on the soft tissue and accordingly he can fabricate the implant restoration with an esthetic emergence. Fig. 8 Appropriate final abutment is selected and prepared in the laboratory to provide the room for the ceramic buildup. The abutment is screwed over the implant (a) and final crown is fixed using the dual cure resin luting cement (b). The preservation of exact soft tissue profile can be seen in this case which resulted in the esthetic emergence for the implant prosthesis. Post loading radiograph (c). Fig. 7 The provisional crown of the anatomical shape is screwed over the implant immediately after the implant placement (a). The anatomic provisional crown has maintained the scalloped soft tissue architecture of the socket, as can be seen after crown is removed for prosthetic phase after 6 month healing of the implant Dr. Ajay Vikram Singh is a keynote speaker at Famdent Show Delhi 2012
  • 5. 87Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012 Soft Tissue Management in Implantation at Healed Site • Soft tissue management - The soft tissue management to achieve the esthetic emergence and esthetic papillae around the implant restoration is a challenge for the implant dentists in cases of healed sites with lost papillae. Careful evaluation of the soft tissue, meticulous treatment planning, ideal implant positioning, crafting the soft tissue to the desired shape and careful dealing with soft tissue during the implant placement and restoration procedures result in achieving the desired esthetic results (Fig. 9 a-d). • The soft tissue grafting - In various cases in day to day implant practice, the soft tissue remains deficient at the implant site, where it may require various type of soft tissue augmentation (epithelialized connective tissue or only connective tissue) procedures to generate the thick, keratinized and attached marginal soft tissue around the implant restoration, which not only provides the esthetic emergence to the implant restoration but also is more resistant to the muscle pull, mechanical and chemical injuries, recession and peri-implantitis (Fig. 10 a-d). Depending on an individual case, the soft tissue grafting procedure can be performed before implant placement, at the time of implant insertion, at the time of uncovering or after the implant restoration but usually it is preferred to be done in most cases at the time of implant uncovering. Summary The presence of a thick, stable and keratinized marginal soft tissue is paramount to achieve the esthetic emergence of the implant restoration as well as for the long term success of the esthetic implant restorations. Efforts should be made to preserve the existing soft tissue at the implant site. Moreover, the presence of compromised soft tissue at the implant site requires the soft tissue augmentation procedures to regenerate the favorable marginal soft tissue at the implant site. At the implant site where the keratinized and stable soft tissue is present Fig. 9 The single piece implant (3.75X15) is placed at the maxillary canine site following the minimal invasive implant placement surgery. The site was edentulous since few years, thus lost the papillae and now regenerating lost papilla around the implant restoration is the challenge in such cases. The implant has achieved adequate primary stability required for non functional restoration. The implant abutment is prepared in the mouth (a) and restored using a provisional crown which is kept well out of occlusion to avoid occlusal forces during implant healing. The flap is sutured around this provisional crown (b). The provisional crown of anatomical shape in the cervical half guided the soft tissue to take the esthetic shape during implant healing. The removal of provisional crown after 6 weeks has resulted in the formation of esthetic scalloped soft tissue profile (c). The final crown at place is showing the acceptable soft tissue emergence and papillae regeneration around the implant restoration (d). Fig. 10 The site with thin, mobile, and non keratinized soft tissue with the see through of the implants cover screws before the implant uncovering (a). Uncovering and restoration of these implants without performing soft tissue augmentation procedure may result in compromised marginal soft tissue around the implant restoration which may cause problems like soft tissue recessions, recurrent peri- implantitis and crestal bone resorption. A full thickness epithelialized connective tissue graft is harvested from the patient’s palate and sutured at the site at the stage of implant uncovering following all the specific protocols of recipient site preparation, and soft tissue grafting (b and c). Regeneration of thick, keratinized band of marginal soft tissue can be seen 4 weeks after the soft tissue grafting (d). This kind of tissue will not only provide esthetic emergence to the implant restoration but is more resistant to muscle pull, recessions, and peri-implantitis.
  • 6. 88Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012 but is showing some kind of soft tissue defect in ridge morphology, the only connective tissue graft harvested from the palate is placed after elevating the partial thickness flap. It enhances the connective tissue thickness and ridge morphology around the implant restoration. In cases where the thin, mobile and non keratinized marginal tissue is present, the partial or full thickness epithelialized soft tissue graft is harvested from the palate or the edentulous ridge area and grafted at the site after elevation of the partial thickness flap and proper recipient site preparation. References 1. Patrick Palacci & Hessam Nowzari: Soft tissue enhancement around dental implants, Periodontology 2000, Vol. 47, 2008, 113–132. 2. Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Tissue modeling following implant placement in fresh extraction sockets. Clin Oral Implants Res 2006: 17: 615–624. 3. Araujo MG, Wennstrom JL, Lindhe J. Modeling of the buccal and lingual bone walls of fresh extraction sites following implant installation. Clin Oral Implants Res 2006: 17: 606–614. 4. Bengazi F, Wennstro¨m JL, Lekholm U. Recession of the soft tissue margin at oral implants. A 2-year longitudinal prospective study. Clin Oral Implants Res 1996: 7: 303–310. 5. Berglundh T, Lindhe J. Dimension of the peri-implant mucosa. Biological width revisited. J Clin Periodontol 1996: 23: 971–973. DENTAL 6. Berglundh T, Abrahamsson I, Welander M, Lang NP, Lindhe J. Morphogenesis of the peri-implant mucosa: an experimental study in dogs. J Clin Oral Implants Res 2007: 18: 1–8. 7. Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative complications following gingival augmentation procedures. J Periodontol 2006: 77: 2070–2079. 8. Grunder U. Stability of the mucosal topography around single-tooth implants and adjacent teeth: 1-year results. Int J Periodontics Restorative Dent 2000: 20: 11–17. 9. Hertel RC, Blijdorp PA, Baker DL. A preventive mucosal flap technique for use in implantology. Int J Oral Maxillofac Implants 1993: 8: 452–458. 10. Israelson H, Plemons JM. Dental implants, regenerative techniques and periodontal plastic surgery to restore maxillary anterior esthetics. Int J Oral Maxillofac Implants 1993: 8: 555–561. 11. Jemt T. Restoring the gingival contour by means of provisional resin crowns after single-implant treatment. Int J Periodontics Restorative Dent 1999: 19: 20. 12. Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent 1997: 17: 326–333. 13. Kamalakidis S, Paniz G, Kang KH, Hirayama H. Nonsurgical management of soft tissue deficiencies for anterior single implant-supported restorations: a clinical report. J Prosthet Dent 2007: 97: 1–5. 14. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans. J Periodontol 2003: 74: 557–562. 15. Liljenberg B, Gualini F, Berglundh T, Tonetti M, Lindhe J. Some characteristics of the ridge mucosa before and after implant installation. A prospective study in humans. J Clin Periodontol 1996: 23: 1008–1013.