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Soft tissue enhancement around dental implants is becoming more and more important in the daily dental practice.
soft tissue management enhacement dental implant neck crown roll-up technique
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 criteria have been raised in the dental implantology, based on the continuous research.

The amount and quality of the gingival soft tissue around the dental implant neck is one of those success criteria being considered nowadays in dental implantology
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 implant has no micro blood vessels around it like a tooth has. The blood support for the bone around a dental implant needs, 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.

In this clinical case we see how a unitary dental implant is placed on the extraction site of a lower first molar that had severe periodontal damage due to an insufficient root canal treatment.

 

This is the resulting state of the attached gingiva after the healing phase, prior to the dental implant exposure surgery.

 

In this exposure surgery, a roll-up soft tissue enhancement technique is employed. This roll-up surgery pursues to increase the attached gingiva thickness on the buccal side around the dental implant neck.
Since the external layer of the flap will be submerged between periosteum and the attached gingiva, this external layer -which served as mastication surface on the edentulous space- needs to be de-epithelized.
De-epithelization is the removal of the thin outer most layer of keratinized cells, so that the flap quickly bonds itself to the inner tissues where it is laid. This is done with a sharp scalpel blade or with a diamond drill.
After rolling in the flap towards the side pouch, it is fixed by means of a 6/0 nylon micro suture, that can be removed after seven days.


The roll-up technique deals with the inside folding of the attached, keratinized gingiva covering the implant, which is moved to the side and rolled in between the periosteum and the outer attached gingiva while creating a pouch for it.

The prosthetical phase starts with the impressions, in this case, with open tray abutments. 
The next step is the design and construction of abutment and crown for the ICX implant on the cast model. This implant model provides platform switch, internal hexagon and cone.
The abutment is screwed onto the implant with 30Ncm torque-control
And the crown is inserted over the abutment. Due to its rounded shape, it pushes somehow the gums while it slides in place, producing temporary ischemia -compromised blood support-, as seen on this pale shade around the crown.
The gums are a flexible tissue and they adapt themselves to the new situation in a matter of minutes or some hours at the most.

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