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Ridge Augmentation II.pptx

This document discusses soft tissue augmentation techniques for ridge defects. It describes various classification systems for soft tissue phenotypes and ridge defects. Common techniques include pedicle grafts like the roll flap procedure and free grafts like subepithelial connective tissue grafts. Factors like tissue thickness, defect size and location must be considered to select the appropriate technique. The goal is to increase keratinized tissue volume and quality for esthetics and prosthetic outcomes.

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RIDGE AUGMENTATION: II SOFT TISSUE AUGMENTATION DR. RINISHA SINHA MDS III DEPARTMENT OF PERIODONTOLOGY
CONTENT Mucogingival therapy or Periodontal Plastic Surgery Soft tissue phenotype Introduction Classification Techniques Advancements or Newer Concepts Conclusion References
MUCOGINGIVAL THERAPY Friedman, 1957 • “Surgical procedures designed to preserve gingiva, remove aberrant frenulum or muscle attachments, and increase the depth of the vestibule.” American Academy of Periodontology, 2001 • General term to describe the periodontal treatment involving procedures for the correction of defects in morphology, position, and/or amount of soft tissue and underlying bone support at teeth and implants. Described for all procedures that involved both the gingiva and the alveolar mucosa
PERIODONTAL PLASTIC SURGERY Miller, 1993 Proceedings of the 1996 World Workshop in Periodontics, 1996 • “Surgical procedures performed to prevent or correct the anatomic, developmental, traumatic or disease-induced defects of the gingiva, alveolar mucosa or bone.” Included treatment procedures are: • Gingival augmentation • Root coverage • Correction of mucosal defects at implants • Crown lengthening • Gingival preservation at ectopic tooth eruption • Removal of aberrant frenulum • Prevention of ridge collapse associated with tooth extraction • Augmentation of the edentulous ridges
PERIODONTAL PHENOTYPE = GINGIVAL BIOTYPE  TISSUE THICKNESS has been reported to be an important factor that influences implant success. References: Wang et al. 2007; Jung, Hammerle. 2007 CLASSIFICATION AUTHORS Scalloped and Thin Flat and Thick Oschenbien and Ross; 1969 Thin Gingival Tissues as <1.5 mm Thick Gingival Tissues as ≥ 2.0 mm Clafey N, Shanley D; 1986 Thin – Scalloped Thick – Flat Siebert and Lindhe; 1989 Flat = 2.1 mm Scalloped = 2.8 mm Pronounced scalloped gingiva = 4.1mm Becker at al. 1997 References: Muller, Eger 1997 References: Jepsen et al. 2018
METHODS TO ASSESS THICKNESS OF SOFT TISSUES Direct method Ultrasonic devices Soft tissue Cone beam computed tomography (CBCT)
Factors affecting soft tissue deficiencies Soft-tissue deficiencies prior to implant placement Tooth loss Periodontal disease Systemic diseases
Soft-tissue deficiencies prior to implant placement encompass the following situations: Improve esthetics Enhance pontic adaptation the available amount of soft tissue does not 1) easily allow soft-tissue coverage of bone volume augmentations; 2) allow tension free primary coverage of the site of implant placement; or 3) allow tension free adaptation of the keratinized soft-tissue flap around the neck of the placed implant
Does the thickness of the soft tissues influences the behavior of the crestal bone during tissue integration of implants? References: Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of soft tissue thickness on crestal bone changes around implants: a 1-year prospective controlled clinical trial. Int J Oral Maxillofac Implants. 2009;24:712–719 References: Kaminaka A, Nakano T, Ono S, Kato T, Yatani H. Conebeam computed tomography evaluation of horizontal and vertical dimensional changes in buccal peri-implant alveolar bone and soft tissue: a 1-year prospective clinical study. Clin Implant Dent Relat Res. 2015;17(Suppl. 2):e576–585. THIN SOFT TISSUES LEAD TO INCREASED MARGINAL BONE LOSS
INTRODUCTION  Tissue deficiencies at implant sites are common clinical findings  Soft-tissue defects include volume and quality deficiencies, i.e. lack of keratinized tissue. References: Acharya A, Hao J, Mattheos N, Chau A, Shirke P, Lang NP. Residual ridge dimensions at edentulous maxillary first molar sites and periodontal bone loss among two ethnic cohorts seeking tooth replacement. Clin Oral Implants Res. 2014;25:1386–1394. References: Thoma DS, Buranawat B, Hammerle CH, Held U, Jung RE. Efficacy of soft tissue augmentation around dental implants and in partially edentulous areas: a systematic review. J Clin Periodontol. 2014;41(Suppl. 15):S77–91. PLASTIC PERIODONTAL PROCEDURES To augment keratinized tissue Apically positioned flap Vestibuloplasty To increase the soft tissue volume Free gingival grafts Sub-epithelial connective tissue grafts Roll and Pedicle grafts References: Cairo et al. 2008; Thoma et al. 2009 References: Thoma et al. 2009 References: Seibert 1983a; Studer et al. 2000 References: Langer B 1980; Abrams L 1980; Rosenberg ES 1982
CORRECTION OF SOFT TISSUE RIDGE DEFECTS SIEBERT; 1983 Class I: Loss of bucco- lingual width but normal apico- coronal height Class II: Loss of apico- coronal height but normal bucco-lingual width Class III: A combination of loss of both height and width of the ridge ALLEN’s 1985 Type A: Apico-coronal loss of tissue Type B: Bucco-lingual loss of tissue Type C: Combination … MILD: Less than 3 mm reduction MODERATE: Between 3 to 6 mm reduction SEVERE: More than 6 mm reduction
Factors to be determined prior to initiation of soft tissue augmentation therapy Volume of tissue required to eliminate the ridge deformity Type of graft procedure to be used Timing of various treatment procedures Design of the provisional Provisional problems tissue discolorations and matching tissue color
SOFT TISSUE AUGMENTATION PROCEDURES Pedicle graft procedures Roll flap procedure Free graft procedures Pouch graft procedures Interpositional graft procedures Onlay graft procedures References: Studer et al. 1997 References: Studer et al. 2000
PEDICLE GRAFT PROCEDURES  Studer et al. 1997  For correction of a single tooth ridge defect  With minor horizontal and vertical loss  Esthetic results  Difficult to perform  Donor site might not be satisfactory due to anatomic considerations and finite tissue thickness
ROLL FLAP PROCEDURE  Abrams 1980  Preparation of a de-epithelialized connective tissue pedicle graft subsequently placed in a sub- epithelial pouch  Indications:  Treatment of small to moderate class I ridge defects  primarily in cases with a single-tooth space  most useful in restoring defects in the apico-coronal dimension but requires sufficient soft tissue thickness directly over and palatal to the residual ridge crest.  Enables  to augment tissue apically and labially to the cervical area of a pontic  To give recipient site the appearance of a normal tooth-gingiva interface  Converts a bucco-lingual ridge concavity into a ridge convexity resembling the eminence produced by the roots of the adjacent teeth References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard. References: Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Dent 1980;1:205.
Technique References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
Adjustment of pontic contours  Common to all soft tissue ridge augmentation procedures in patients with fixed bridgework  A light contact is maintained between the pedicle graft and the tissue surface of the pontics  Post-operative swelling conforms to the shape of the pontic  Enables to shape the soft tissue into a form that is intended for the augmented site References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
Post-operative care Periodontal dressing is placed over the donor site; to be changed at weekly intervals and maintained until wound healing has progressed to a point where the tissue is no longer tender to touch. No dressing to be placed over the facial (labial) surface of the grafted area where the swelling will occur References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
FREE GRAFT PROCEDURES Studer et al. 2000 Submerged free connective tissue graft procedure for larger defects Onlay full-thickness graft procedure for ridge augmentation in presence of additional mucogingival problems such as insufficient gingival width, high frenum, gingival scarring or tattoo References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
SUBEPITHELIAL CONNECTIVE TISSUE GRAFT  Garber & Rosenberg 1981  Preferred over free gingival grafts, especially in areas with high esthetic impact  Advantages:  More gain in tissue volume  Better color and texture match  Disadvantages:  Significant shrinkage of grafts following the augmentation procedure References: Edel et al. 1974; Nemcovsky et al. 2000 References: Mormann et al. 1981; Studer et al. 2000; Thoma et al. 2010.
 Kaldahl et al. 1982; Seibert 1983; Allen et al. 1985; Miller 1986; Cohen 1994  Subepithelial pouch is prepared in the area of the ridge deformity, into which a free graft of connective tissue is placed and molded to create the desired contour of the ridge POUCH GRAFT PROCEDURES  Indications:  To correct class I defects  If large-volume defects may have thin palatal tissues  insufficient to provide the volume of the donor tissue necessary to fill the deformity  hard tissue augmentation procedures to be selected.
Entrance incision and the plane of dissection may be made in different ways: 1. CORONAL-APICALLY the horizontal incision is made on the palatal or lingual side of the defect and the plane of dissection carried in an apical direction References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
2. APICAL-CORONALLY the horizontal incision is made high in the vestibule near the mucobuccal fold and the plane of dissection is carried coronally to the crest of the ridge 3. LATERALLY one or tow vertical entrance incisions are started from either side of the defect. The plane of dissection is made laterally across the span of the deformity. (80) References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
HEALING OF FREE SOFT TISSUE GRAFT References: Oliver, Loe, Karring et al. 1968; Janson et al. 1969
 Seibert 1991, 1993 a,b  Not completely submerged and covered in the manner that a subepithelial connective tissue graft is placed  No need to remove the epithelium from the surface of the donor tissue  Indications:  When augmentation is required in both bucco-lingual and apico-coronal direction, a position of the graft must be positioned above the surface of the tissue surrounding the recipient site  To correct class I as well as small to moderate class II defects  Thus, a certain amount of the grafted connective tissue will be exposed in the oral cavity  Large amount of donor tissue INTERPOSITIONAL GRAFT PROCEDURES
a. Pre-treatment view: Class III ridge defect – A two-stage procedure used b. A pouch was prepared to receive an interpositional graft; epithelium removed from the borders of the recipient site to permit some graft to be placed above the level of surrounding tissue (gaining apico- coronal augmentation) c. Wedge-shaped graft – 10 mm thick at the center d. Interpositional graft is both displacing the labial surface of the pouch in the labial directions as well as adding height to the ridge e. 2 months post-op – Additional augmentation needed f. A second-stage onlay graft used to create a papilla and fill the dark triangle between the pontics
 Meltzer 1979; Seibert 1983  Epithelized free grafts  Indications:  To augment ridge defects in apico-coronal plane i.e. to gain ridge height  In treatment of large class II and III defects  Not suitable in areas where the blood supply at the recipient site has been compromised by scar tissue formation from previous wound healing  Following placement, receive their nutrition from the de-epithelialized connective tissue of the recipient site  Amount of apico-coronal augmentation is related to the initial thickness of the graft, the events of the wound healing processes, and the amount of grafts tissue that survives  If necessary, can be repeated at 2-month intervals to gradually increase the ridge height ONLAY GRAFT PROCEDURES
Selection of donor site Require large amount of donor tissue Palatal vault region of premolars and first molars, midway between the gingival margin and the midline raphae is the only area in the maxilla that contains necessary volume of tissue required to augment large ridge defects Tissue to be probed with a 30-gauge syringe needle to ensure that an acceptable volume of tissue can be obtained at the time of surgery Major palatine artery emerges from the posterior palatine foramen located adjacent to the distal surface of the maxillary second molar, midway between the gingival margin and the midline raphae Artery passes in an anterior direction close to the surface of the palatal bone Important therefore that the second and third molar regions are not used as donor site for large volume grafts References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
Dissection of donor tissue Base of the graft should be V- or U- shaped to match the shape of the defect in the ridge Therefore the different planes of incision in the palate must converge towards an area under the center or toward one edge of the donor site Comparatively easy with the use of a scalpel to dissect in an antero-posterior or from an area high in the palate in a lateral direction towards the teeth Difficult to dissect in an anterior direction from the distal edge of the donor site Variety of blade holders available which permit the scalpel blade to be positioned at different angles to the holder and which enables the surgeon to cut with a back-action After removal of the donor tissue, it must be stored in pieces of surgical gauze moistened in isotonic saline at all times
Treatment of the donor site Difficult to anchor and maintain a periodontal dressing at the donor site in the palatal vault, an acrylic stent should be fabricated prior to surgery Stent to be made with wrought wire clasps on each side to add retention and to aid the patient in removing and inserting the device Donor site must be inspected carefully for signs of arterial bleeding If any small vessel bleeding is observed, a circumferential suture must be placed around the vessel distal to the bleeding point Immediately thereafter the void at the donor site should be packed with a suitable hemostatic agent and the edges of the wound be brought closer together with sutures Then put stent into position
Try-in and stabilization of graft Graft is transferred with tissue forceps to the recipient site for a try-in. Graft is trimmed to the proper shape and adjusted to fit the connective tissue surface of the prepared ridge A series of parallel cuts may be made deep into the exposed lamina propria of the recipient site to sever large blood vessels immediately before suturing Series of interrupted sutures is placed along the borders of the graft Assistant stabilizes the onlay graft against the surface of the recipient site, while placement of sutures is done References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
Wound healing in the recipient site Considerable post-operative swelling often occurs during the first week after pouch and onlay augmentation procedures The epithelium of the graft will slough to form a white film on the surface of the graft Patients should rinse two-four times per day with an antimicrobial mouthwash during the first week after surgery Refrain from mechanical cleaning measures in the area until a new epithelial covering has formed over the graft, which will not occur until a functional capillary circulation has been re-established in the graft (4-7 days after the surgery) Grafted tissue will assume a normal color as the epithelium thickens via stratification Stable tissue form after 3 months but further shrinkage may occur over a period of several months Final restorative measures should not be initiated until after 6 months
Wound healing in the donor site Granulation tissue will gradually fill the donor site Initial healing – complete within 3-4 weeks after the removal of a 4-5 mm thick graft Patient to wear surgical stent for about 2 weeks to protect the healing wound Palate returns to its pre-surgical contour after about 3 months
g. 2 months after the first surgical procedure, ridge was de-epitheliliazed and cuts were made into the connective tissue prior to placing the second-stage onlay graft into position h. The onlay graft was sutured into position i. The pontics were adjjusted and brought into light contact with the graft j. Marked swelling occurred within the graft at 14 days post-surgery k. 2 months following the surgical procedure, gingivoplasty was done l. Post-treatment view 1 year after the final surgical procedure
 Seibert & Louis 1996  Indications:  Class III : major challenge;  to be augmented in both vertical and horizontal dimensions COMBINED ONLAY-INTERPOSITIONAL GRAFT PROCEDURES
Advantages Submerged connective tissue section of the interpositional graft aids in the revascularisation of the onlay section of the graft, thereby gaining a greater percentage of take of the overall graft A smaller post-operative open wound in the palate donor site Faster healing in the palate donor site with less patient discomfort Greater latitude or ability to control the degree of bucco-lingual and apico- coronal augmentation within a single procedure Vestibular depth is not decreased and the muco gingival junction is not moved coronally, thereby eliminating the need for follow-up corrective procedures
a. & b. The right maxillary lateral and central incisors were lost due to trauma. These views show the horizontal and vertical loss of ridge tissue 10 months after the extractions. c. A partial-thickness path of incision was extended labially and apically to create a pouch. The amount of space created within the pouch and the degree of relaxation of the flap was tested with a periosteal elevator. d. The epithelialized section of the graft. e. The premolar area, maxillary right side, was used as a donor area. The area of exposed connective tissue corresponds to the onlay section of the graft. The incisions were extended another 5–7 mm towards the midline on a long bevel to obtain the interpositional segment of the graft. f. The graft was tucked into the labial pouch and sutured first along its palatal border. The labial flap was then sutured along the epithelial connective border of the graft. The residual labial socket defect in the flap created a soft tissue discontinuity defect along the labial margin of the flap. g. At 6 weeks post surgery, further augmentation would be required to gain additional soft tissue in both the vertical and horizontal planes. Second-stage procedure was done at this time. h. An incision 1.5 mm in depth utilized to de-epithelialize the crestal surface of the ridge. papillae were not included within the surgical field. The mesial and distal borders of the onlay section of the recipient site were then extended apically to create vertical releasing incisions. The overall recipient site was to be trapezoidal in shape. A labial flap to create the pouch section of the recipient site was made using partial- thickness dissection. i. The left maxillary premolar area was used as the donor site for the second-stage surgery. j. This side view clearly shows the epithelialized onlay section of the graft and the de-epithelialized connective tissue section of the graft, as well as tissue thickness.
k. The graft was sutured first along the fixed palatal border to gain initial stabilization. Then the connective tissue interpositional section was sutured along the lateral borders. The flap was then sutured over the interpositional section of the graft at the epithelialized edge of the onlay section of the graft and along the vertical incisions. l. At 6 weeks post surgery, the provisional prosthesis was modified to bring the tissue surface of the pontics into contact with the healing ridge. m. At 2 months post surgery, tooth form was further modified on the provisional prosthesis and gingivoplasty was done to sculpt the tissues to final form and smooth out surface irregularities. n. The final ceramo-metal prosthesis was inserted 4 months later. The life-like reconstruction of the soft tissues and dentition restored dentofacial esthetics for the patient.
ADVANCEMENTS / NEWER CONCEPTS
ACELLULAR DERMAL MATRIX  An acellular dermal matrix designed to serve as a biologic scaffold for normal tissue remodeling. Derived from donated human skin.  ADM contains both the structure and the biochemical information to direct normal revascularization and cell repopulation because blood vessels, collagens, proteoglycans, and elastin are preserved.  This extracellular matrix contains the blood vessel channels that serve as conduits for revascularization  Collagens, proteoglycans, and elastin provide structure and information for cell repopulation.  Most importantly, preserved proteoglycans and proteins direct the patient’s own cells to initiate revascularization and cell repopulation.  Grafted ADMs maintain their ultrastructural acellular matrix integrity and do not provoke a rejection or inflammatory response in host tissues.  Does not have the limitations in availability that palatal donor tissue does. References: Wainwright et al. 1996; Eppley 2000
INDICATIONS Skin burn management For correction of gingival recession Bone regeneration Soft tissue ridge augmentation Minimise soft tissue fenestration prior to block grafting References: Wainwright et al. 1996 References: Henderson et al. 2001 References: Fowler et al. 2000 References: Harris et al. 2003; Batista and Batista 2001 References: AlGhamdi and Buhite, 2008
Implant site preparation with osetotome Folding the ADM and stabilization with sutures Flap closure 10 days follow-up 8 weeks healing
VASCULARIZED INTERPOSITIONAL PERIOSTEAL CONNECTIVE TISSUE FLAP  A novel pedicle autograft  ADVANTAGES:  Excellent blood supply,  Less morbidity,  Primary closure of donor and recipient bed  Does not alter the color of the area  More agreeable to the patient because it involves a single surgical site References: Agarwal, et al.: Ridge augmentation using VIP-CT flap References: Sclar A. Vascularized interpositional periosteal-connective tissue (VIP-CT) flap. In: Sclar A, editor. Soft Tissue and Esthetic Considerations in Implant Dentistry. Chicago: Quintessence Publishing; 2003. p. 163-87. Kim CS, Jang YJ, Choi SH, Cho KS. Long-term results from soft and hard tissue augmentation by a modified vascularized interpositional periosteal-connective tissue technique in the maxillary anterior region. J Oral Maxillofac Surg 2012;70:484-91.
TRANSMUCOSAL PERIOSTEAL RELEASING INCISION: THE “BUTTONHOLE TECHNIQUE” References: Aranda J et al. Clinical Advances in Periodontics, Vol. 5, No. 2, May 2015
References: Aranda J et al. Clinical Advances in Periodontics, Vol. 5, No. 2, May 2015
THE DOME TECHNIQUE References: Irinakis T, Aldahlawi S. The dome technique: a new surgical technique to enhance soft-tissue margins and emergence profiles around implants placed in the esthetic zone. Clin Cosmet Investig Dent. 2018;10:1-7
SELF-INFLATING SOFT TISSUE EXPANDERS References: Dhadse P et al. J Indian Soc Periodontol, 2014 Jul-Aug; 18(4): 433- 440.
CONCLUSION The reconstruction with autografts can be broadly divided into 3 major groups: • free gingival grafts, • free buccal mucosa grafts, • and buccal fat pad grafts. Require large amounts of tissue which cannot always be easily harvested in the oral cavity; therefore, new materials are being developed, that is, from allogeneic, xenogeneic, and synthetic origin or alloplastic materials. Self-inflating soft tissue hydrogel expanders successfully used to acquire surplus amounts of soft tissue to cover bone grafts. Advantages - their high biocompatibility, low complication rates, non- genotoxic and non-immune reactivity, material pureness, and safety which subsequently ensures a low risk of infection. Drawbacks, such as patient discomfort during expansion and waiting time of 6 to 10 weeks; a second surgery required to remove the expander and simultaneously perform a bone augmentation, only a limited amount of tissue can be expanded in comparison to alloplastic materials Collagen matrix, resembles the extracellular matrix, widely used for soft tissue augmentation. Disadvantages such as low mechanical stiffness and rapid biodegradation, lack important ECM proteins. Therefore, acellularized xenogenic tissues - a promising alternative material for soft tissue regeneration because they maintain their 3D structure and subsequently offer good mechanical properties. Recently, tissue-engineered three-dimensional (3D) oral mucosal grafts have been tested and could offer a promising alternative to conventional grafts.
Newman, Takei, Klokkevold, Carranza: Carrazanza’s Clinical Periodontology, Saunders, 10th edition. Jan Wolff, DDS, Dr Med Dent, Elisabet Farré-Guasch; Soft Tissue Augmentation Techniques and Materials Used in the Oral Cavity: An Overview; Implant Dentistry; Volume 25; Number 3; 2016 Lindhe, Lang, Karring: Clinical Periodontology and Implant Dentistry. Blackwell Munksgaard, 5th edition. Urban IA, Montero E, Monje A, Sanz- Sánchez I. Effectiveness of vertical ridge augmentation interventions: A systematic review and meta-analysis. J Clin Periodontol. 2019 Jun;46 Suppl 21:319-339. Goyal M, Mittal N, Gupta GK, Singhal M. Ridge augmentation in implant dentistry. J Int Clin Dent Res Organ 2015;7:94-112. Linkevicius T, Apse P , Grybauskas S, Puisys A. The influence of soft tissue thickness on crestal bone changes around implants: a 1- year prospective controlled clinical trial. Int J Oral Maxillofac Implants. 2009;24:712–719 Dhadse P et al. J Indian Soc Periodontol, 2014 Jul-Aug; 18(4): 433-440. Thoma DS, Buranawat B, Hammerle CH, Held U, Jung RE. Efficacy of soft tissue augmentation around dental implants and in partially edentulous areas: a systematic review. Periodontol 2000. 2014;41(Suppl. 15):S77–91.
Ridge Augmentation II.pptx

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Ridge Augmentation II.pptx

  • 1.
    RIDGE AUGMENTATION: II SOFTTISSUE AUGMENTATION DR. RINISHA SINHA MDS III DEPARTMENT OF PERIODONTOLOGY
  • 2.
    CONTENT Mucogingival therapy orPeriodontal Plastic Surgery Soft tissue phenotype Introduction Classification Techniques Advancements or Newer Concepts Conclusion References
  • 3.
    MUCOGINGIVAL THERAPY Friedman, 1957 •“Surgical procedures designed to preserve gingiva, remove aberrant frenulum or muscle attachments, and increase the depth of the vestibule.” American Academy of Periodontology, 2001 • General term to describe the periodontal treatment involving procedures for the correction of defects in morphology, position, and/or amount of soft tissue and underlying bone support at teeth and implants. Described for all procedures that involved both the gingiva and the alveolar mucosa
  • 4.
    PERIODONTAL PLASTIC SURGERY Miller,1993 Proceedings of the 1996 World Workshop in Periodontics, 1996 • “Surgical procedures performed to prevent or correct the anatomic, developmental, traumatic or disease-induced defects of the gingiva, alveolar mucosa or bone.” Included treatment procedures are: • Gingival augmentation • Root coverage • Correction of mucosal defects at implants • Crown lengthening • Gingival preservation at ectopic tooth eruption • Removal of aberrant frenulum • Prevention of ridge collapse associated with tooth extraction • Augmentation of the edentulous ridges
  • 5.
    PERIODONTAL PHENOTYPE = GINGIVALBIOTYPE  TISSUE THICKNESS has been reported to be an important factor that influences implant success. References: Wang et al. 2007; Jung, Hammerle. 2007 CLASSIFICATION AUTHORS Scalloped and Thin Flat and Thick Oschenbien and Ross; 1969 Thin Gingival Tissues as <1.5 mm Thick Gingival Tissues as ≥ 2.0 mm Clafey N, Shanley D; 1986 Thin – Scalloped Thick – Flat Siebert and Lindhe; 1989 Flat = 2.1 mm Scalloped = 2.8 mm Pronounced scalloped gingiva = 4.1mm Becker at al. 1997 References: Muller, Eger 1997 References: Jepsen et al. 2018
  • 6.
    METHODS TO ASSESSTHICKNESS OF SOFT TISSUES Direct method Ultrasonic devices Soft tissue Cone beam computed tomography (CBCT)
  • 7.
    Factors affecting softtissue deficiencies Soft-tissue deficiencies prior to implant placement Tooth loss Periodontal disease Systemic diseases
  • 8.
    Soft-tissue deficiencies priorto implant placement encompass the following situations: Improve esthetics Enhance pontic adaptation the available amount of soft tissue does not 1) easily allow soft-tissue coverage of bone volume augmentations; 2) allow tension free primary coverage of the site of implant placement; or 3) allow tension free adaptation of the keratinized soft-tissue flap around the neck of the placed implant
  • 9.
    Does the thicknessof the soft tissues influences the behavior of the crestal bone during tissue integration of implants? References: Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of soft tissue thickness on crestal bone changes around implants: a 1-year prospective controlled clinical trial. Int J Oral Maxillofac Implants. 2009;24:712–719 References: Kaminaka A, Nakano T, Ono S, Kato T, Yatani H. Conebeam computed tomography evaluation of horizontal and vertical dimensional changes in buccal peri-implant alveolar bone and soft tissue: a 1-year prospective clinical study. Clin Implant Dent Relat Res. 2015;17(Suppl. 2):e576–585. THIN SOFT TISSUES LEAD TO INCREASED MARGINAL BONE LOSS
  • 10.
    INTRODUCTION  Tissue deficienciesat implant sites are common clinical findings  Soft-tissue defects include volume and quality deficiencies, i.e. lack of keratinized tissue. References: Acharya A, Hao J, Mattheos N, Chau A, Shirke P, Lang NP. Residual ridge dimensions at edentulous maxillary first molar sites and periodontal bone loss among two ethnic cohorts seeking tooth replacement. Clin Oral Implants Res. 2014;25:1386–1394. References: Thoma DS, Buranawat B, Hammerle CH, Held U, Jung RE. Efficacy of soft tissue augmentation around dental implants and in partially edentulous areas: a systematic review. J Clin Periodontol. 2014;41(Suppl. 15):S77–91. PLASTIC PERIODONTAL PROCEDURES To augment keratinized tissue Apically positioned flap Vestibuloplasty To increase the soft tissue volume Free gingival grafts Sub-epithelial connective tissue grafts Roll and Pedicle grafts References: Cairo et al. 2008; Thoma et al. 2009 References: Thoma et al. 2009 References: Seibert 1983a; Studer et al. 2000 References: Langer B 1980; Abrams L 1980; Rosenberg ES 1982
  • 11.
    CORRECTION OF SOFTTISSUE RIDGE DEFECTS SIEBERT; 1983 Class I: Loss of bucco- lingual width but normal apico- coronal height Class II: Loss of apico- coronal height but normal bucco-lingual width Class III: A combination of loss of both height and width of the ridge ALLEN’s 1985 Type A: Apico-coronal loss of tissue Type B: Bucco-lingual loss of tissue Type C: Combination … MILD: Less than 3 mm reduction MODERATE: Between 3 to 6 mm reduction SEVERE: More than 6 mm reduction
  • 12.
    Factors to bedetermined prior to initiation of soft tissue augmentation therapy Volume of tissue required to eliminate the ridge deformity Type of graft procedure to be used Timing of various treatment procedures Design of the provisional Provisional problems tissue discolorations and matching tissue color
  • 13.
    SOFT TISSUE AUGMENTATION PROCEDURES Pediclegraft procedures Roll flap procedure Free graft procedures Pouch graft procedures Interpositional graft procedures Onlay graft procedures References: Studer et al. 1997 References: Studer et al. 2000
  • 14.
    PEDICLE GRAFT PROCEDURES Studer et al. 1997  For correction of a single tooth ridge defect  With minor horizontal and vertical loss  Esthetic results  Difficult to perform  Donor site might not be satisfactory due to anatomic considerations and finite tissue thickness
  • 15.
    ROLL FLAP PROCEDURE Abrams 1980  Preparation of a de-epithelialized connective tissue pedicle graft subsequently placed in a sub- epithelial pouch  Indications:  Treatment of small to moderate class I ridge defects  primarily in cases with a single-tooth space  most useful in restoring defects in the apico-coronal dimension but requires sufficient soft tissue thickness directly over and palatal to the residual ridge crest.  Enables  to augment tissue apically and labially to the cervical area of a pontic  To give recipient site the appearance of a normal tooth-gingiva interface  Converts a bucco-lingual ridge concavity into a ridge convexity resembling the eminence produced by the roots of the adjacent teeth References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard. References: Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Dent 1980;1:205.
  • 16.
    Technique References: Lindhe,J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
  • 18.
    Adjustment of ponticcontours  Common to all soft tissue ridge augmentation procedures in patients with fixed bridgework  A light contact is maintained between the pedicle graft and the tissue surface of the pontics  Post-operative swelling conforms to the shape of the pontic  Enables to shape the soft tissue into a form that is intended for the augmented site References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
  • 19.
    Post-operative care Periodontal dressingis placed over the donor site; to be changed at weekly intervals and maintained until wound healing has progressed to a point where the tissue is no longer tender to touch. No dressing to be placed over the facial (labial) surface of the grafted area where the swelling will occur References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
  • 20.
    FREE GRAFT PROCEDURES Studeret al. 2000 Submerged free connective tissue graft procedure for larger defects Onlay full-thickness graft procedure for ridge augmentation in presence of additional mucogingival problems such as insufficient gingival width, high frenum, gingival scarring or tattoo References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
  • 21.
    SUBEPITHELIAL CONNECTIVE TISSUEGRAFT  Garber & Rosenberg 1981  Preferred over free gingival grafts, especially in areas with high esthetic impact  Advantages:  More gain in tissue volume  Better color and texture match  Disadvantages:  Significant shrinkage of grafts following the augmentation procedure References: Edel et al. 1974; Nemcovsky et al. 2000 References: Mormann et al. 1981; Studer et al. 2000; Thoma et al. 2010.
  • 22.
     Kaldahl etal. 1982; Seibert 1983; Allen et al. 1985; Miller 1986; Cohen 1994  Subepithelial pouch is prepared in the area of the ridge deformity, into which a free graft of connective tissue is placed and molded to create the desired contour of the ridge POUCH GRAFT PROCEDURES  Indications:  To correct class I defects  If large-volume defects may have thin palatal tissues  insufficient to provide the volume of the donor tissue necessary to fill the deformity  hard tissue augmentation procedures to be selected.
  • 23.
    Entrance incision andthe plane of dissection may be made in different ways: 1. CORONAL-APICALLY the horizontal incision is made on the palatal or lingual side of the defect and the plane of dissection carried in an apical direction References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
  • 24.
    2. APICAL-CORONALLY the horizontalincision is made high in the vestibule near the mucobuccal fold and the plane of dissection is carried coronally to the crest of the ridge 3. LATERALLY one or tow vertical entrance incisions are started from either side of the defect. The plane of dissection is made laterally across the span of the deformity. (80) References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
  • 25.
    HEALING OF FREESOFT TISSUE GRAFT References: Oliver, Loe, Karring et al. 1968; Janson et al. 1969
  • 26.
     Seibert 1991,1993 a,b  Not completely submerged and covered in the manner that a subepithelial connective tissue graft is placed  No need to remove the epithelium from the surface of the donor tissue  Indications:  When augmentation is required in both bucco-lingual and apico-coronal direction, a position of the graft must be positioned above the surface of the tissue surrounding the recipient site  To correct class I as well as small to moderate class II defects  Thus, a certain amount of the grafted connective tissue will be exposed in the oral cavity  Large amount of donor tissue INTERPOSITIONAL GRAFT PROCEDURES
  • 28.
    a. Pre-treatment view:Class III ridge defect – A two-stage procedure used b. A pouch was prepared to receive an interpositional graft; epithelium removed from the borders of the recipient site to permit some graft to be placed above the level of surrounding tissue (gaining apico- coronal augmentation) c. Wedge-shaped graft – 10 mm thick at the center d. Interpositional graft is both displacing the labial surface of the pouch in the labial directions as well as adding height to the ridge e. 2 months post-op – Additional augmentation needed f. A second-stage onlay graft used to create a papilla and fill the dark triangle between the pontics
  • 29.
     Meltzer 1979;Seibert 1983  Epithelized free grafts  Indications:  To augment ridge defects in apico-coronal plane i.e. to gain ridge height  In treatment of large class II and III defects  Not suitable in areas where the blood supply at the recipient site has been compromised by scar tissue formation from previous wound healing  Following placement, receive their nutrition from the de-epithelialized connective tissue of the recipient site  Amount of apico-coronal augmentation is related to the initial thickness of the graft, the events of the wound healing processes, and the amount of grafts tissue that survives  If necessary, can be repeated at 2-month intervals to gradually increase the ridge height ONLAY GRAFT PROCEDURES
  • 30.
    Selection of donorsite Require large amount of donor tissue Palatal vault region of premolars and first molars, midway between the gingival margin and the midline raphae is the only area in the maxilla that contains necessary volume of tissue required to augment large ridge defects Tissue to be probed with a 30-gauge syringe needle to ensure that an acceptable volume of tissue can be obtained at the time of surgery Major palatine artery emerges from the posterior palatine foramen located adjacent to the distal surface of the maxillary second molar, midway between the gingival margin and the midline raphae Artery passes in an anterior direction close to the surface of the palatal bone Important therefore that the second and third molar regions are not used as donor site for large volume grafts References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
  • 31.
    Dissection of donortissue Base of the graft should be V- or U- shaped to match the shape of the defect in the ridge Therefore the different planes of incision in the palate must converge towards an area under the center or toward one edge of the donor site Comparatively easy with the use of a scalpel to dissect in an antero-posterior or from an area high in the palate in a lateral direction towards the teeth Difficult to dissect in an anterior direction from the distal edge of the donor site Variety of blade holders available which permit the scalpel blade to be positioned at different angles to the holder and which enables the surgeon to cut with a back-action After removal of the donor tissue, it must be stored in pieces of surgical gauze moistened in isotonic saline at all times
  • 32.
    Treatment of thedonor site Difficult to anchor and maintain a periodontal dressing at the donor site in the palatal vault, an acrylic stent should be fabricated prior to surgery Stent to be made with wrought wire clasps on each side to add retention and to aid the patient in removing and inserting the device Donor site must be inspected carefully for signs of arterial bleeding If any small vessel bleeding is observed, a circumferential suture must be placed around the vessel distal to the bleeding point Immediately thereafter the void at the donor site should be packed with a suitable hemostatic agent and the edges of the wound be brought closer together with sutures Then put stent into position
  • 33.
    Try-in and stabilizationof graft Graft is transferred with tissue forceps to the recipient site for a try-in. Graft is trimmed to the proper shape and adjusted to fit the connective tissue surface of the prepared ridge A series of parallel cuts may be made deep into the exposed lamina propria of the recipient site to sever large blood vessels immediately before suturing Series of interrupted sutures is placed along the borders of the graft Assistant stabilizes the onlay graft against the surface of the recipient site, while placement of sutures is done References: Lindhe, J., Lang, N. P., & Karring, T. (2008). Clinical periodontology and implant dentistry. Oxford: Blackwell Munksgaard.
  • 34.
    Wound healing inthe recipient site Considerable post-operative swelling often occurs during the first week after pouch and onlay augmentation procedures The epithelium of the graft will slough to form a white film on the surface of the graft Patients should rinse two-four times per day with an antimicrobial mouthwash during the first week after surgery Refrain from mechanical cleaning measures in the area until a new epithelial covering has formed over the graft, which will not occur until a functional capillary circulation has been re-established in the graft (4-7 days after the surgery) Grafted tissue will assume a normal color as the epithelium thickens via stratification Stable tissue form after 3 months but further shrinkage may occur over a period of several months Final restorative measures should not be initiated until after 6 months
  • 35.
    Wound healing inthe donor site Granulation tissue will gradually fill the donor site Initial healing – complete within 3-4 weeks after the removal of a 4-5 mm thick graft Patient to wear surgical stent for about 2 weeks to protect the healing wound Palate returns to its pre-surgical contour after about 3 months
  • 36.
    g. 2 monthsafter the first surgical procedure, ridge was de-epitheliliazed and cuts were made into the connective tissue prior to placing the second-stage onlay graft into position h. The onlay graft was sutured into position i. The pontics were adjjusted and brought into light contact with the graft j. Marked swelling occurred within the graft at 14 days post-surgery k. 2 months following the surgical procedure, gingivoplasty was done l. Post-treatment view 1 year after the final surgical procedure
  • 37.
     Seibert &Louis 1996  Indications:  Class III : major challenge;  to be augmented in both vertical and horizontal dimensions COMBINED ONLAY-INTERPOSITIONAL GRAFT PROCEDURES
  • 38.
    Advantages Submerged connective tissue sectionof the interpositional graft aids in the revascularisation of the onlay section of the graft, thereby gaining a greater percentage of take of the overall graft A smaller post-operative open wound in the palate donor site Faster healing in the palate donor site with less patient discomfort Greater latitude or ability to control the degree of bucco-lingual and apico- coronal augmentation within a single procedure Vestibular depth is not decreased and the muco gingival junction is not moved coronally, thereby eliminating the need for follow-up corrective procedures
  • 40.
    a. & b.The right maxillary lateral and central incisors were lost due to trauma. These views show the horizontal and vertical loss of ridge tissue 10 months after the extractions. c. A partial-thickness path of incision was extended labially and apically to create a pouch. The amount of space created within the pouch and the degree of relaxation of the flap was tested with a periosteal elevator. d. The epithelialized section of the graft. e. The premolar area, maxillary right side, was used as a donor area. The area of exposed connective tissue corresponds to the onlay section of the graft. The incisions were extended another 5–7 mm towards the midline on a long bevel to obtain the interpositional segment of the graft. f. The graft was tucked into the labial pouch and sutured first along its palatal border. The labial flap was then sutured along the epithelial connective border of the graft. The residual labial socket defect in the flap created a soft tissue discontinuity defect along the labial margin of the flap. g. At 6 weeks post surgery, further augmentation would be required to gain additional soft tissue in both the vertical and horizontal planes. Second-stage procedure was done at this time. h. An incision 1.5 mm in depth utilized to de-epithelialize the crestal surface of the ridge. papillae were not included within the surgical field. The mesial and distal borders of the onlay section of the recipient site were then extended apically to create vertical releasing incisions. The overall recipient site was to be trapezoidal in shape. A labial flap to create the pouch section of the recipient site was made using partial- thickness dissection. i. The left maxillary premolar area was used as the donor site for the second-stage surgery. j. This side view clearly shows the epithelialized onlay section of the graft and the de-epithelialized connective tissue section of the graft, as well as tissue thickness.
  • 41.
    k. The graftwas sutured first along the fixed palatal border to gain initial stabilization. Then the connective tissue interpositional section was sutured along the lateral borders. The flap was then sutured over the interpositional section of the graft at the epithelialized edge of the onlay section of the graft and along the vertical incisions. l. At 6 weeks post surgery, the provisional prosthesis was modified to bring the tissue surface of the pontics into contact with the healing ridge. m. At 2 months post surgery, tooth form was further modified on the provisional prosthesis and gingivoplasty was done to sculpt the tissues to final form and smooth out surface irregularities. n. The final ceramo-metal prosthesis was inserted 4 months later. The life-like reconstruction of the soft tissues and dentition restored dentofacial esthetics for the patient.
  • 42.
  • 43.
    ACELLULAR DERMAL MATRIX An acellular dermal matrix designed to serve as a biologic scaffold for normal tissue remodeling. Derived from donated human skin.  ADM contains both the structure and the biochemical information to direct normal revascularization and cell repopulation because blood vessels, collagens, proteoglycans, and elastin are preserved.  This extracellular matrix contains the blood vessel channels that serve as conduits for revascularization  Collagens, proteoglycans, and elastin provide structure and information for cell repopulation.  Most importantly, preserved proteoglycans and proteins direct the patient’s own cells to initiate revascularization and cell repopulation.  Grafted ADMs maintain their ultrastructural acellular matrix integrity and do not provoke a rejection or inflammatory response in host tissues.  Does not have the limitations in availability that palatal donor tissue does. References: Wainwright et al. 1996; Eppley 2000
  • 44.
    INDICATIONS Skin burn management Forcorrection of gingival recession Bone regeneration Soft tissue ridge augmentation Minimise soft tissue fenestration prior to block grafting References: Wainwright et al. 1996 References: Henderson et al. 2001 References: Fowler et al. 2000 References: Harris et al. 2003; Batista and Batista 2001 References: AlGhamdi and Buhite, 2008
  • 45.
    Implant site preparationwith osetotome Folding the ADM and stabilization with sutures Flap closure 10 days follow-up 8 weeks healing
  • 46.
    VASCULARIZED INTERPOSITIONAL PERIOSTEAL CONNECTIVETISSUE FLAP  A novel pedicle autograft  ADVANTAGES:  Excellent blood supply,  Less morbidity,  Primary closure of donor and recipient bed  Does not alter the color of the area  More agreeable to the patient because it involves a single surgical site References: Agarwal, et al.: Ridge augmentation using VIP-CT flap References: Sclar A. Vascularized interpositional periosteal-connective tissue (VIP-CT) flap. In: Sclar A, editor. Soft Tissue and Esthetic Considerations in Implant Dentistry. Chicago: Quintessence Publishing; 2003. p. 163-87. Kim CS, Jang YJ, Choi SH, Cho KS. Long-term results from soft and hard tissue augmentation by a modified vascularized interpositional periosteal-connective tissue technique in the maxillary anterior region. J Oral Maxillofac Surg 2012;70:484-91.
  • 48.
    TRANSMUCOSAL PERIOSTEAL RELEASING INCISION:THE “BUTTONHOLE TECHNIQUE” References: Aranda J et al. Clinical Advances in Periodontics, Vol. 5, No. 2, May 2015
  • 49.
    References: Aranda Jet al. Clinical Advances in Periodontics, Vol. 5, No. 2, May 2015
  • 50.
    THE DOME TECHNIQUE References:Irinakis T, Aldahlawi S. The dome technique: a new surgical technique to enhance soft-tissue margins and emergence profiles around implants placed in the esthetic zone. Clin Cosmet Investig Dent. 2018;10:1-7
  • 51.
  • 52.
    CONCLUSION The reconstruction with autograftscan be broadly divided into 3 major groups: • free gingival grafts, • free buccal mucosa grafts, • and buccal fat pad grafts. Require large amounts of tissue which cannot always be easily harvested in the oral cavity; therefore, new materials are being developed, that is, from allogeneic, xenogeneic, and synthetic origin or alloplastic materials. Self-inflating soft tissue hydrogel expanders successfully used to acquire surplus amounts of soft tissue to cover bone grafts. Advantages - their high biocompatibility, low complication rates, non- genotoxic and non-immune reactivity, material pureness, and safety which subsequently ensures a low risk of infection. Drawbacks, such as patient discomfort during expansion and waiting time of 6 to 10 weeks; a second surgery required to remove the expander and simultaneously perform a bone augmentation, only a limited amount of tissue can be expanded in comparison to alloplastic materials Collagen matrix, resembles the extracellular matrix, widely used for soft tissue augmentation. Disadvantages such as low mechanical stiffness and rapid biodegradation, lack important ECM proteins. Therefore, acellularized xenogenic tissues - a promising alternative material for soft tissue regeneration because they maintain their 3D structure and subsequently offer good mechanical properties. Recently, tissue-engineered three-dimensional (3D) oral mucosal grafts have been tested and could offer a promising alternative to conventional grafts.
  • 53.
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