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Soft tissue management around two mandibular implants

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 management enhacement technique dental implant neck
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.


control diagnose soft tissue management around dental implants lateral viewcontrol diagnose soft tissue management around dental implants lateral view


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.

soft tissue management around dental implants diagnose X-ray

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 parallelsoft tissue management surgery around dental ICX implants lateral viewsoft 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

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

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



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

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


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 abutmentssoft tissue management surgery around dental ICX implants impression abutments
The impression is taken with Impregum, polyether material.
dental ICX implants impression abutmentsICX implants impression abutments tray

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.
distalization molar implant mesial tipping  third molar extraction
distalization molar implant mesial tipping  third molar extraction wedgedistalization molar implant mesial tipping  crown wedge
 

Buccal bone wall protection on a maxillary bicuspid

Buccal bone wall protection on a maxillary bicuspid

The width of the buccal wall of a dental implant is becoming more and more important for its long term durability.
Placing the dental implant with 1,5 to 2 milimeters away from the buccal wall provides the bone wall with enough blood supply.

3,75x12,5" ICX-Templant internal hexagon under bone-level concavity buccal bone wallBio-Oss Bio-Guide GBR material buccal bone wall

Opposite to teeth, whose surrounding bone receives plenty of blood support from the periodontal ligament, the implant have no ligament and no surrounding blood circulation. Thus the buccal wall blood support comes only from the periosteum and the transeptal blood vessels.

Providing the buccal bone wall with a good thickness allows the internal bone blood vessels to supply nutrients to the buccal bone.

  • Diagnosis:
The X-ray shows two edentulous spaces on a 60 year-old man, non-smoker. Thick biotype.

occlusal view, upper jawPanoramic diagnostic X-ray implant surgeryocclusal view, lower jaw
 
Lateral right view, pre-operatoryFront view, preo-operatoryLateral left view, pre-operatory dental implant surgery
 
 
Preoperatory diagnostic measures. Control of the soft tissue quantity and quality
lateral right, invagination soft tissue attached gingivaocclusal right showing invagination soft tissue, mirror view

as well as a2D X-ray measurement with 5″ balls.
 
Panoramic diagnostic X-ray measurement balls dental implant surgery
  • Implant placement surgery

Regular split flap with two vertical discharges mesial and distal of the spot. Bone condensing carried out to finally place a 3,75×12,5″ ICX-Templant (internal hexagon) insertion after bone spreading.
The implant is placed 1mm under the bone level. This allows some typical crestal bone resorption while still keeping the internal cone properties of the implant. Notice the concavity of the buccal wall under the ridge level.

Bio-Oss Bio-Guide GBR buccal bone wall3,75x12,53,75x12,5" ICX-Templant internal hexagon under bone-level concavity buccal bone wall
Bio-Oss and Bio-Guide GBR material protecting the buccal bone wall. This increases the initial volume and adds extra hard tissue substance to the buccal wall.
 
 
Panoramic post-operatory X-ray 3,75x12,5" ICX-Templant implants
Panoramic post-operatory X-ray, after placing two 3,75×12,5″ ICX-Templant internal hexagon dental implants.
 
 
Suture with 4/0 Prolene.
 
4/0 suture wund4/0 suture wund
 
and healing sequence after 2, 5 and 9 weeks
2 weeks, implant surgery wund healing

9 weeks, implant exposure  surgery wund healed, lateral right view40 days, implant surgery wund healing, occlusal mirror view9 weeks, implant surgery wund healed, occlusal mirror view

 

  • Implant exposure surgery after 9 weeks

a regular exposure surgery, with a minimal incision from the palatinal side, and the tissue buccally displaced. Healing abutment over a 3,75×12,5″ ICX-Templant (internal hexagon)

implant exposure surgery, tissue buccally displaced. Healing abutment 3,75x12,5" ICX-Templant (internal hexagon)implant exposure surgery, tissue buccally displaced healing abutment 3,75x12,5" ICX-Templant (internal hexagon)

3 weeks after the exposure surgery, with the healing abutment.

3 week inplant exposure surgery healing abutment over the 3,75x12,5" ICX-Templant (internal hexagon)3 week implant exposure surgery healing abutment 3,75x12,5" ICX-Templant (internal hexagon)
  • Prosthetical phase

Impression transfer for a closed tray.

 
Impression transfer abutment 3 week 3,75x12,5" ICX-Templant (internal hexagon)
3,75×12,5″ ICX-Templant (internal hexagon) abutment on cast lab modell showing the platform switch, with the corresponding crown
 
3,75x12,5" ICX-Templant (internal hexagon) abutment cast lab modell platform switch3,75x12,5" ICX-Templant (internal hexagon) abutment crown3,75x12,5" ICX-Templant (internal hexagon) abutment cast lab modell platform switch, crown
 
3,75×12,5″ ICX-Templant (internal hexagon) abutment emerging. Screwed at 30Ncm torque.

3,75x12,5" ICX-Templant (internal hexagon) abutment 3,75x12,5" ICX-Templant (internal hexagon) abutment occlusal mirror view
  • Crown insertion
Metal-ceramic crown placed on the 3,75×12,5″ ICX-Templant (internal hexagon) abutment. Notice the metal line at the gum level, due to slight gingival retraction
 
Metal-ceramic crown implant 3,75x12,5" ICX-Templant (internal hexagon) abutment. metal line gum level  gingival retractionICX-Templant (internal hexagon) abutment. metal line gum level  gingival retraction
 
 
7 weeks after insertion. The metal-ceramic crown placed on the 3,75×12,5″ ICX-Templant (internal hexagon) abutment. Notice that the metal line at the gum level has dissapeared, due to gingival re-growth
 
ICX-Templant (internal hexagon) abutment. metal line gum level  gingival retractionICX-Templant (internal hexagon) abutment. metal line gum level  gingival retraction
 
occlusal mirror view of the final result
3,75x12,5" ICX-Templant internal hexagon3,75x12,5" ICX-Templant internal hexagon ceramic crown
 
 
 
 
 
 
 
 
Buccal bone wall protection on a mandibulary molar

Buccal bone wall protection on a mandibulary molar

Opposite to teeth, whose surrounding bone receives plenty of blood support from the periodontal ligament, the implant have no ligament and no surrounding blood circulation. Thus the buccal wall blood support comes only from the periosteum and the transeptal blood vessels.
Providing the buccal bone wall with a good thickness allows the internal bone blood vessels to supply nutrients to the buccal bone.
bone cavity ICX-Templant internal hexagon bone level dental implant
protecting the buccal bone wall
Bone graft autologous bone Bio-Oss buccal wall
with bone graft and membrane

The width of the buccal wall of a dental implant is becoming more and more important for its long term durability.
Placing the dental implant with 1,5 to 2 milimeters away from the buccal wall provides the bone wall with enough blood supply.
 
  • Diagnosis:
The X-ray shows two edentulous spaces on a 60 year-old man, non-smoker. Thick biotype.
occlusal view, upper jawPanoramic diagnostic X-ray implant surgeryocclusal view, lower jaw
Lateral right view, pre-operatory dental implant surgeryFront view, preo-operatory dental implant surgeryLateral left view, pre-operatory dental implant surgery

Preoperatory diagnostic measures. Control of the soft tissue quantity and quality

pre-operatory soft tissue vertical lateral bone resorption reduced attached gingiva height, dental implant surgery

pre-operatory soft tissue vertical lateral bone resorption reduced attached gingiva height, dental implant surgerypre-operatory soft tissue vertical lateral bone resorption reduced attached gingiva height, dental implant surgery

pre-operatory soft tissue vertical lateral bone resorption reduced attached gingiva height, dental implant surgerypre-operatory soft tissue vertical lateral bone resorption reduced attached gingiva height, dental implant surgery
as well as a2D X-ray measurement with 5″ diameter balls.
Panoramic diagnostic X-ray measurement balls dental implant surgery
  • Implant placement surgery
Regular split flap with only one vertical discharge mesial of the spot. 
The 3,75×12,5″ ICX-Templant (internal hexagon) dental implant is placed 1mm under the bone level. This allows some typical crestal bone resorption while still keeping the internal cone properties of the implant. Notice the concavity of the buccal wall under the ridge level.
 
bone cavity ICX-Templant internal hexagon bone level dental implant
Bio-Oss and Bio-Guide GBR material protecting the buccal bone wall. This increases the initial volume and adds extra hard tissue substance to the buccal wall.
Bone graft autologous bone Bio-Oss buccal wallBio-Guide collagen membrane bone graft autologous bone Bio-Oss dental implant
Panoramic post-operatory X-ray, after placing two 3,75×12,5″ ICX-Templant internal hexagon dental implants.
Panoramic post-operatory X-ray 3,75x12,5" ICX-Templant implants
Suture of the flap with 4/0 Prolene.
Suture 4/0 prolene
healing sequence after 2 weeks,
Healing phase 2 weeks implant surgery
and after and 9 weeks
soft tissue implant surgery lateral volume increase

soft tissue implant surgery lateral volume increase

  • Implant exposure surgery 
after 8 weeks a partial thickness displacement flap is moved buccally, with the incision beginning well on the lingual side, The keratinized tissue is displaced buccally. 6″ Healing abutment over the 3,75×12,5″ ICX-Templant (internal hexagon)
 
Implant exposure surgery. Buccally displacement flap increase attached gingiva buccal wallImplant exposure surgery. Buccally displacement flap increase attached gingiva buccal wallImplant exposure surgery. Buccally displacement flap increase attached gingiva buccal wall
3 weeks after the exposure surgery, with the healing abutment.
 
Implant exposure surgery. Buccally displacement flap increase attached gingiva buccal wall
  • Prosthetical phase

Impression transfer for a closed tray.

Implant exposure surgery. Buccally displacement flap increase attached gingiva buccal wall impression abutment
 
3,75×12,5″ ICX-Templant (internal hexagon) abutment on cast lab model showing the platform switch, with the corresponding crown
 
Cast model platform swtiching abutmet ICX-Templant 3,75" analogCast model platform swtiching ICX-Templant 3,75" analog
Cast model platform swtiching abutment ICX-Templant 3,75" analog crownCast model platform swtiching abutment ICX-Templatnt 3,75" analog
Soft tissue 6 weeks after the implant exposure surgery. 6″ healing abutment.
 
Soft tissue implant exposure surgery healing abutment ICX-Templant 3,75"Soft tissue implant exposure surgery healing abutment ICX-Templant 3,75"
3,75×12,5″ ICX-Templant (internal hexagon) abutment emerging. Screwed at 30Ncm torque.
Soft tissue implant exposure surgery healing abutment ICX-Templant 3,75"
  • Crown insertion
Metal-ceramic crown placed on the 3,75×12,5″ ICX-Templant (internal hexagon) abutment. Notice the metal line at the gum level, due to slight gingival retraction
Soft tissue implant exposure surgery crown abutment ICX-Templant 3,75"
Soft tissue 12 weeks after the implant exposure surgery, 6 weeks after crown placement.
Soft tissue implant exposure surgery healing crown abutment ICX-Templant 3,75"Soft tissue implant exposure surgery healing crown abutment ICX-Templant 3,75"Soft tissue implant exposure surgery healing crown abutment ICX-Templant 3,75"