soft tissue management with implant dr. ajay vikram singh

80Famdent Practical Dentistry Handbook Vol. 13 Issue 1 July - Sept. 2012

Management Of Soft Tissue Esthetics In Implant DentistryDr. Ajay Vikram Singh

Dr. Ajay Vikram Singh, after completing his BDS, received PG certificate training in Implantology from India followed by advanced level implant

training at different centers and continuing education implant programmes in USA. He is an internationally acclaimed mentor, speaker and

researcher in the field of implantology. He has spoken as the key note speaker in different national and international implant conferences. Besides

being an active member of many prestigious implant associations, he is a Fellow and Diplomate of International Congress of Implantology. He

has been running basic to advanced level implant training programmes at his Implant Center, at Agra since 2005 and has trained many national

as well as international dentists with his implant skills. Dr. Ajay can be reached at – [email protected]

Dr. Sunita Singh

Dr. Sunita Singh, after completing her BDS received a lot of continuing her education in Esthetic And Implant Dentistry and Fixed Orthodontics

at different Centers in India and USA. She has attended and presented her skills in many national and international Dental Conferences. She

has taken special training in Cosmetic Dentistry at the Continuing Education Programme at Washington University (USA). She is a member

of American College of Prosthodontists in USA. She is an active member of Indian Academy of Aesthetic and Cosmetic Dentistry as well as

Academy of Oral Implantology. She has been practicing with Dr. Ajay since 2003 at Dr. Ajay Dental Clinic and Research Center, Agra.

Introduction

The successful use of dental implants to replace missing teeth has

been one of the most popular, exciting and evolving areas of clinical

dentistry. When implants are thought as a treatment option, treatment

planning has become more complex for the dental practitioner and

an interdisciplinary team approach is recommended to achieve a long

term esthetic as well as functional outcome in the implant restorations.

Failure to demonstrate such an approach might lead to undesirable

esthetic and functional implant complications. The long term clinical

and esthetic success of an implant retained restoration is determined

by stable peri-implant soft tissue morphology in hormone with the

surrounding soft tissues and natural dentition. In addition to successful

osseointegration of the implant, the surrounding soft tissues play an

important role in the vascularization of the underlying bone. Insufficient

soft tissue causes improper nutrient supply the underlying peri-implant

bone and may lead to crestal bone resorption after implant is restored

in function. Proper gingival architecture is especially important in the

implants placed in the esthetic region. Thorough treatment planning

and knowledge of the specific phases of inflammatory and regenerative

processes associated with wound healing are essential for predictable

esthetic results. Preoperative deficiency of the soft tissue often mandates

the extensive soft tissue management, mobilization and augmentation

procedures to obtain the esthetics around the implant restorations.

Various soft tissue management and augmentation techniques are

applied to obtain adequate esthetic emergence profile of the implant

restoration with sufficient keratinized gingiva. However, efforts should

be made to preserve the existing esthetic soft tissue profile by implant

placement with minimal soft tissue injury during implant insertion

and uncovering and also by supporting the soft tissue architecture

using a provisional prosthesis during subgingival or open healing of

the implant. Immediate implantation in the extraction socket with an

anatomical provisional restoration, which is immediately fixed after the

implant insertion to support the soft tissue profile of the socket, should

be practiced in the esthetic region. Optimizing implant placement,

particularly position and angulation, allows the clinician not only to

approximate the form of the original dentition, but to create an esthetic

soft-tissue contour and provide a long-term function.

• Favorableandunfavorablesofttissuesaroundtheimplant

The keratinized and stable soft tissue with thick biotype is the

favorable tissue for long term implant health as it is more

resistant to chemical and mechanical injuries, muscle pull, etc.

(Fig. 1) and thus prevent the occurrence of peri-implantitis and

Fig. 1 Thin, non keratinized and mobile marginal soft tissue is less resistant to the muscle pull and recedes, which may result in recurrent peri-implantitis and subsequent peri-implant crestal bone loss.


crestal bone loss. In short, for the long term health of the implant

restoration minimum 2-3 mm of thick, keratinized and attached

marginal soft tissue should be present. Efforts should be made

to preserve the existing keratinized tissue at the implant site

by closely evaluating the type of soft tissue biotype and accordingly

planning the incisions and implant placement protocols to

minimise the loss or recession of the favorable marginal soft

tissue. A thick, keratinized and non mobile marginal soft tissue

offers several advantages such as protect the peri-implant tissues

from injury and infection, resist the pull of muscles, resistant to

the marginal soft tissue recession, better plaque control, adequate

soft tissue esthetics, etc. (Fig. 2)

Soft Tissue Biotypes

Gingival thickness, its morphology, presence of interdental papilla

and the osseous architecture at the site are all determining factors

in periodontal biotyping and can influence surgical approaches and

healing in the field of implantology. Ochsenbein & Ross described

healthy periodontal tissues by the biotype categories of thin scalloped

(thin gingival tissue, long papillae and thin scalloped bone) and

thick flat (thick gingival tissue, short and wide papillae and thick, flat

bone). Olsson & Lindhe further categorized the periodontium based

on the associated tooth form and susceptibility to gingival recession.

The triangular tooth form is associated with a scalloped and thin

periodontium. The contact area for the triangular tooth shape is at

the coronal third of the crown, supporting a long and thin papilla.

The squared tooth combines with a thick and flat periodontium. The

contact area for the square tooth shape is at the middle third of the

crown, supporting a short and wide papilla. Periodontal biotyping

affects practically all periodontal surgical procedures, including crown

lengthening, implant placement and tissue grafting. A thin periodontal

biotype is the more technique-sensitive and can post-treatment, give

rise to gingival recession or black triangle formation. An implant placed

in a site with a thin periodontal biotype may develop mucosal recession

or bluish color changes.

Soft Tissue Management

Peri-implant mucosal height essentially follows the crest of the

alveolar bone; however, the determining factors in inter implant

papilla development are complex and may not be fully controlled by

implant design features or surgical interventions. Although bone height

and thickness are major determinants of soft tissue height, factors

such as tooth morphology, location of the interdental contact point

and arrangement and quality of soft tissue fibers can also influence

soft tissue appearance. Lack of dento-gingivo-alveolar circular,

semicircular, transeptal, interpapillary and intergingival fibers around

implants constitutes a major obstacle in soft tissue appearance and

management around implants. The absence of inter implant papillae

causing an inter-implant black triangle continues to be a significant

problem in dental implant esthetics. The type of provisional prosthesis

used during the healing period is critical for optimal healing. The

design of the provisional restoration should be based on thorough

diagnostic information and provide minimal post surgical irritation

and pressure on soft tissues. A proper interim prosthesis can provide

valuable suggestions about the esthetic appearance of the definitive

restoration. The thickness, height and contour of the facial alveolar

plate can significantly affect the labial position, the facial expression

and the smile. There is a wide range of variation in the morphology of

the alveolar plate. A dynamic balance between functional forces and

existing alveolar bone shape sculpts the alveolar bone morphology.

The housing of a standard 3.75–4mm diameter implant requires 6 mm

of bone in the bucco–lingual dimension and 5–6 mm of bone in the

mesio–distal dimension. Both thickness and height of the facial alveolar

plate are influenced by implant angulation. A lingual implant inclination

is associated with a thick and flat facial alveolar bone that provides soft

tissue support in a more coronal position than normal. A labial implant

inclination is associated with a thin and scalloped facial alveolar bone

that often is located in an apical position. Lingually inclined anterior

implants provide a thicker coronal portion of the facial alveolar plate

and counteract a tendency to peri-implant bone resorption. Vertical

and horizontal enlargements of the facial alveolar plate prior to implant

placement can be critical for the long-term maintenance of soft tissue

height. Limitations in bone quantity in the mesio–distal dimension may

be caused by root position of adjacent. Tooth morphology is related

to the periodontal biotype and this phenomenon is most evident in

the anterior esthetic zone of the mouth. The triangular shaped tooth

is linked to a thin, scalloped periodontium (Biotype I). In this biotype,

the interproximal contact area is located in the coronal one-third of

the crown and is associated with a long and thin papilla. The square-

shaped tooth is connected to a thick and flat periodontium (Biotype

II). The interproximal contact area is located at the middle one-third

of the crown and supports a short, wide papilla of teeth. Orthodontic

movement used to change the root position can provide the necessary

space for implant insertion. A reduced horizontal distance between a

tooth and a neighboring implant may adversely affect the bone level

at the tooth side.

Fig. 2 A thick, keratinized and stable marginal soft tissue offers several advantages such as protect the peri-implant tissues from injury and infection, resist the pull of muscles, resistant to the marginal soft tissue recession, better plaque control, adequate soft tissue esthetics, etc.


Case Report - 1 Soft Tissue Preservation In Case Of Immediate

Implantation In Esthetic Region

Immediate implantation cases have been and continue to be the

challenge in providing immediate and long term esthetic and functional

implant restorations. The conventional delayed implant placement may

result in loss of hard and soft tissue architectures of the socket as part

of natural healing processes. The unsupported papillae get lost during

the healing phase of the socket and often result in flat soft tissue at the

ridge crest and black triangles around the implant prosthesis. Immediate

implantation with immediate restoration supports the present soft tissue

architecture and also guides the soft tissue to take a desired shape

to provide final restoration with esthetic emergence. But immediate

implantation with immediate functional or nonfunctional restoration is

a technique sensitive procedure as it needs the implant positioning at

the ideal place in the socket, achieving initial stability of the inserted

implant which is adequate for immediate restoration, grafting of peri-

implant socket spaces and immediate fabrication and placement of a

provisional restoration of the desired anatomic shape (Figs. 3 to 8).

Fig. 3 A 40 year male patient presented with mobile tooth no. 21. (a) The dental radiograph revealed the root fracture with some amount of vertical bone resorption (b) For minimal invasive flapless implant placement, the site is planned with CT cross section to place the implant at the ideal position and axis (c) The longest possible implant with its placement slightly towards palatal position to provide room for the regeneration of thick volume of hard and soft tissue on the facial aspect and to stabilize the implant in the high density nasal floor to achieve adequate primary stability so that the implant can immediately be restored, was planned.

Fig. 4 The tooth and its fractured root are extracted out using periotomes and luxators with minimal trauma to the bone and soft tissue (a). The osseous topography was evaluated, all the granulation tissue was currated out of the socket and socket is disinfected using clindamycin to kill residual pathogens. The root dimensions are measured using calipers to decide the appropriate implant size. The implant osteotomy is prepared into the socket, slightly palatal to the long axis of the socket using side cutting Lindemann drills (b) An implant with dimensions of 4.2 X 16 is placed at the correct three dimensional position (c&d)The implant apex is stabilized in the high density nasal floor to achieve adequate bone implant contact percentage and primary stability (more than 35Ncm) of the implant. The implant platform is placed 2-3 mm apical to the cemento-enamel junction of the adjacent teeth and palatal to the imaginary line joining the facial aspects of the CEJ of two adjacent teeth. This provides adequate amount of tissue for esthetic emergence of the implant prosthesis.

Fig. 5 The periimplant socket spaces are grafted using a mixture of HA (70%) and ß Tcp (30%) bone substitute without using any barrier membrane (a). An appropriate abutment is selected, prepared and composite is build up over its surface in the anatomical shape of natural tooth at cervical part to provide adequate support to the marginal soft tissue and papillae and also to prevent the loss of graft from the site (b). The abutment is screwed onto the implant (c).


Fig. 6 A provisional prosthesis is fabricated onto this abutment in mouth using custom poly crown. A screw hole is prepared through the crown to access the connection screw (a). The provisional crown along with abutment is removed from the implant and screwed to the analog to shape the provisional crown (b and c).

Fig. 7 (b). At this stage transferring the same soft tissue profile from the mouth to the working cast with the implant impression is paramount to fabricate the final crown with same anatomic shape at the cervical half. Thus the closed tray impression transfer abutment is inserted over the implants and simultaneously the soft tissue socket spaces are filled with flow composite (c). The impression is made using a silicon material and this impression abutment along with composite remain bonded to it is transferred to the impression with same orientation, which results is the transfer of the exactly same soft tissue profile to the working cast. This helps the technician to understand the anatomical shape on the soft tissue and accordingly he can fabricate the implant restoration with an esthetic emergence.

Fig. 8 Appropriate final abutment is selected and prepared in the laboratory to provide the room for the ceramic buildup. The abutment is screwed over the implant (a) and final crown is fixed using the dual cure resin luting cement (b). The preservation of exact soft tissue profile can be seen in this case which resulted in the esthetic emergence for the implant prosthesis. Post loading radiograph (c).

Fig. 7 The provisional crown of the anatomical shape is screwed over the implant immediately after the implant placement (a). The anatomic provisional crown has maintained the scalloped soft tissue architecture of the socket, as can be seen after crown is removed for prosthetic phase after 6 month healing of the implant

Dr. Ajay Vikram Singh is a keynote speaker at Famdent Show Delhi 2012


Soft Tissue Management in Implantation at Healed Site

• Soft tissue management - The soft tissue management to

achieve the esthetic emergence and esthetic papillae around the

implant restoration is a challenge for the implant dentists in cases

of healed sites with lost papillae. Careful evaluation of the

soft tissue, meticulous treatment planning, ideal implant

positioning, crafting the soft tissue to the desired shape and

careful dealing with soft tissue during the implant placement and

restoration procedures result in achieving the desired esthetic

results (Fig. 9 a-d).

• The soft tissue grafting - In various cases in day to day

implant practice, the soft tissue remains deficient at the implant

site, where it may require various type of soft tissue augmentation

(epithelialized connective tissue or only connective tissue)

procedures to generate the thick, keratinized and attached

marginal soft tissue around the implant restoration, which not

only provides the esthetic emergence to the implant restoration but

also is more resistant to the muscle pull, mechanical and chemical

injuries, recession and peri-implantitis (Fig. 10 a-d). Depending on

an individual case, the soft tissue grafting procedure can be

performed before implant placement, at the time of implant

insertion, at the time of uncovering or after the implant restoration

but usually it is preferred to be done in most cases at the time of

implant uncovering.

Summary

The presence of a thick, stable and keratinized marginal soft tissue

is paramount to achieve the esthetic emergence of the implant

restoration as well as for the long term success of the esthetic implant

restorations. Efforts should be made to preserve the existing soft tissue

at the implant site. Moreover, the presence of compromised soft tissue

at the implant site requires the soft tissue augmentation procedures

to regenerate the favorable marginal soft tissue at the implant site. At

the implant site where the keratinized and stable soft tissue is present

Fig. 9 The single piece implant (3.75X15) is placed at the maxillary canine site following the minimal invasive implant placement surgery. The site was edentulous since few years, thus lost the papillae and now regenerating lost papilla around the implant restoration is the challenge in such cases. The implant has achieved adequate primary stability required for non functional restoration. The implant abutment is prepared in the mouth (a) and restored using a provisional crown which is kept well out of occlusion to avoid occlusal forces during implant healing. The flap is sutured around this provisional crown (b). The provisional crown of anatomical shape in the cervical half guided the soft tissue to take the esthetic shape during implant healing. The removal of provisional crown after 6 weeks has resulted in the formation of esthetic scalloped soft tissue profile (c). The final crown at place is showing the acceptable soft tissue emergence and papillae regeneration around the implant restoration (d).

Fig. 10 The site with thin, mobile, and non keratinized soft tissue with the see through of the implants cover screws before the implant uncovering (a). Uncovering and restoration of these implants without performing soft tissue augmentation procedure may result in compromised marginal soft tissue around the implant restoration which may cause problems like soft tissue recessions, recurrent peri-implantitis and crestal bone resorption. A full thickness epithelialized connective tissue graft is harvested from the patient’s palate and sutured at the site at the stage of implant uncovering following all the specific protocols of recipient site preparation, and soft tissue grafting (b and c). Regeneration of thick, keratinized band of marginal soft tissue can be seen 4 weeks after the soft tissue grafting (d). This kind of tissue will not only provide esthetic emergence to the implant restoration but is more resistant to muscle pull, recessions, and peri-implantitis.


but is showing some kind of soft tissue defect in ridge morphology,

the only connective tissue graft harvested from the palate is placed

after elevating the partial thickness flap. It enhances the connective

tissue thickness and ridge morphology around the implant restoration.

In cases where the thin, mobile and non keratinized marginal tissue

is present, the partial or full thickness epithelialized soft tissue graft is

harvested from the palate or the edentulous ridge area and grafted at

the site after elevation of the partial thickness flap and proper recipient

site preparation.

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soft tissue management with implant dr. ajay vikram singh

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