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roll-up soft tissue enhancement around dental implants

roll-up soft tissue enhancement around dental implants

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.

 

Distalizing a molar to correct mesial tipping with implants and no orthodontics

Mesial tipping behind an extraction site is a normal phenomenon that can be corrected using a simple acrylic wedge and some patience, from both patient and dentist.
Here I show how to distalize a tooth in order to correct the mesial tipping without using orthodontics.
 
 
distalization molar implant mesial tipping third molar extraction X-raydistalization molar implant mesial tipping wedge design
distalization molar implant mesial tipping third molar extractiondistalization molar implant mesial tipping crown

*this is the continuation of the previous post, which shows the surgical soft tissue management phase

First make your design and explain it to the patient and to your dental technician.
The goal in this case was to fit a longer disto-mesial crown on the back implant that tilts the second molar back to a more upright angle. 
Notice that is is reciprocal. The crown won’t fit in the place unless the gap is made somehow bigger before the insertion.
distalization molar implant mesial tipping wedge design cast model
For that we need a simple aid. That is, for example, a chairside made acrylic wedge that you make over the future crown abutments on the cast model or directly in the mouth.  It can also be done in the lab, if you prefer.
There are, however, two ways to approach the solution at this point:
  1. You make the acrylic wedge with the actual size, then you add acrylic distal increments
    1. This is more precise, but it requires a second impression and thus, more time.
  2. You take some cast material from the mesial side of the tooth to be tipped back, then you build the acrylic wedge on the model.
distalization molar implant mesial tipping wedge design cast modeldistalization molar implant mesial tipping wedge design cast model
    • This allows to prepare the final crown and to have it ready as soon as the molar tips back and lets the crown in.
    • But not valid for screwed crowns if the gap opening is more than 1″ on average.
abutment implant ICX
abutment implant ICX
distalization molar implant mesial tipping third molar extraction

In this clinical case I chose the second way and I gave the patient both the edge and the crowns, instructing her to take them in and out until the crowns fit in.

 A second molar can hardly be tipped back if there is a wisdom tooth behind it. So I extracted the third molar and inserted the acrylic wedge on the same day. 
On the hand design you may see I planned to insert the front crown and only a wedge on the back implant, but the I tested it and realized that the wedge was more stable with a double post retention. But it could have been also done with one abutment.
 
distalization molar implant mesial tipping wedge design

The wedge must adapt passively on the front and ut must have an inclined rear surface that pushes the molar back while the occlussion keeps the wedge in place.

distalization molar implant mesial tipping third molar extractionThere will be subsequently an increased bite heigth, resulting in no front contacts and premature contact on the wedge and the implants underneath.
 
 
 
Caution:
  • You may want to allow the implants a longer healing period just to assure full osseointegration
  • You need to tell the patient that he/she should not overload the implants by bitting hardly on them, and that the molar will move back gently in a few days or a few weeks, depending on different factors (bone density, extraction distally, degree of tipping vs. amount of distal movement).
  • You may need to schedule some control appointments, checking how the molar moves back and the bite closes down. If that doesn’t happen, you may need to introduce some changes in your wedge design or confirm that the patient carries it at all times. 
distalization molar implant mesial tipping wedge design open bitedistalization molar implant mesial tipping wedge design open bite

 

There will be a moment, days or weeks later, when the crown can be placed on the abutment and fits in with more or less pressure. This can be done by the dentist or also by the patient at home, providing he/she was properly instructed on this task. Normally it is the crown itself that pushes the tooth back the last tenths of millimiter and falls right in place.

abutment implant ICXabutment implant ICX crown
abutment implant ICX crownsoft tissue management abutment implant ICX crown
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"
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Combined case. Restorations, Orthodontics, Implants & Veneers. Five & ten year results.


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This a long, multidisciplinary case, involving peridontics, endodontics, resin restorations, orthodontics, implants and venners.You can view the full process here…

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Restorative phase
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Orthodontics
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Orthodontics & Implants on 12, 35
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Removal of orthodontics, bleaching & retainer
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Prosthetic Phase & retainer
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results: 5yrs post implantary phase, 10yrs from restoration
alexis sanchez
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