Soft tissue management around two mandibular implants

Soft tissue enhancement around dental implants is becoming more and more important in the daily dental practice.

soft tissue enhancement around a dental implant crown

At the beginning of the dental implants era, we thought that just placing the dental implant on a prosthetically convenient place and achieving a proper osseointegration was already a success. Today the success criteriahave been raised in the dental implantology, based on the continuous research.

How soft tissue protects the implant

The amount and quality of the gingival soft tissue around the dental implant neck is one of those success criteriabeing considered nowadays in dental implatology

After years of experience, it has been demonstrated that the more soft tissue there is around a dental implant, the better its long-term prognosis is.

This is because the dental implanthas no micro blood vessels around it like a tooth has. The blood support for the bone around a dental implantneeds, therefore, to come extra from the soft gingival tissue, since the internal bony circulation is quite limited.

Thus, surgical techniques have been developed to provide the dental implant neck with more surrounding soft tissue.

The buccal soft tissue can be of three kinds, free gingival tissue, attached gingival tissue and alveolar mucosa.

The free gingiva is made of non keratinized tissue. It surrounds the neck of teeth and implants and its inner side forms the gingival sulcus.
The attached gingival tissue is made of keratinized fibers and it is associated to masticatory function. It lays between the alveolar mucosa and the gingival groove. It has a characteristic orange-peel stipplings in a healthy state.
The alveolar mucosa is the non keratinized continuation of the attached gingiva towards the cheeks and lips. It is movable, too. Between this two there is a characteristic line, limiting what is attached and what is movable.

The attached gingiva has proved to be the most deciding part in the long-term preservation of the ridge bone around the dental implant neck. You want to have as much of this tissue around your dental implant as possible. Obviously it cannot be augmented infinitely beyond the anatomical boundaries and the surrounding soft tissue limits. There is an intimate relationship between the bone ridge laying underneath and the soft tissue above it.

soft tissue management around dental implants occlusal view

soft tissue management around dental implants diagnose X-ray

soft tissue management around dental implants lateral view

Clinical soft tissue management case

In this clinical case we see how two dental implants are placed on the left lower jaw, after a long term period without teeth. 50 year-old woman, non smoker, thick biotype.

Diagnose

By clinical examination we appreciate light vertical bone resorption, mid horizontal resorption -thanks to the thick biotype pattern- but indeed a remarkable recession of the attached gingiva. The mesio-distal gap between adjacent teeth is 23mm.

The 5″ diameter measurement balls show panoramic 2D X-ray show enough bone depth for two 12,5″ ICX-Templant implants on both sides. We will discuss the left side on this post only.

Implant surgery

The purpose of this surgery is not only to place the implants, but also to enhance the attached gingiva on the spot. This means a partial thickness epithelial flap -leaving the periosteum on the bone-, displacing the flap buccally (to the side) and apically (downwards), and open healing.

Incision

Contrary to a normal implant surgery, where the upper incision is done right on the ridge, in this case we want to displace as much keratinized epithelium from the lingual side and fix it bucally. we need also two vertical discharges along which the flap will be moved.

soft tissue management surgery around dental implants lateral view

Implant placement

Two 3,75×12,5″ ICX-Templant internal hexagon conus implants are placed with no complications. The buccal bone wall appears to be thick enough so as not to need bone graft protection, regarding especially the fact that there will be supposedly less bone loss by not detaching the periosteum

soft tissue management surgery around dental implants lateral view parallel

soft tissue management surgery around dental ICX implants lateral view

soft tissue management surgery around dental ICX implants lateral view bone level

The implants are place at bone ridge level and, due to the periosteum thickness, they appear to be more submerged.

Suture of the flap

Now it is time to screw the healing abutments (3″ hight in this case) and to reposition the flap bucally with 6/0 Prolene stitches on the periosteum.

Removing the suture stitches

The gum tissue needs now quite a few week to re-epithelize the area, while the implants complete the osseointegration phase. The stitches can be removed one or two weeks after the surgery, but in this it was done 4 weeks later, because the patient leaves a few hours away from the office and cannot come so easily. I try to adapt the appointments to other work stages on the right side, ceramic inlays and other conservative general dentistry therapies.

At this stage an enhancement of the attached gingiva can already be seen buccally.

This is the resulting state of the attached gingiva after the healing phase. 14 weeks in this case, but it could have done by the 8th week or even earlier. The benefit os this first surgery technique is that it needs dental implant exposure surgery at this second stage.

The result is a new thicker keratinized attached gingival band around the dental implant necks.

soft tissue management surgery around dental ICX implants lateral view bone level healing abutments

Impressions

Two impression abutments are fixed on the implants and the plastic tray is perforated conveniently to let the abutments thorugh.

soft tissue management surgery around dental ICX implants impression abutments

The impression is taken with Impregum, polyether material.

dental ICX implants impression abutments

Prosthetical phase

In the next post I will explain how I corrected the mesial inclination of the second molar and placed a wider crown on the 36 implant.

Soft tissue management around two mandibular implants

How soft tissue protects the implant