Soft-Tissue Management for Implant Therapy
Gingival grafting improves long-term protection, stability, and esthetics
Ehab Moussa, DDS, MSD
Regarding implant therapy, many years ago, David Garber, DMD, noted that "the tissue is the issue, but the bone sets the tone." Today, this statement could not be truer, because we now realize and appreciate the role of soft-tissue management/grafting in implant dentistry more than ever before. Although research has demonstrated that implants surrounded by inadequate keratinized tissue often present with plaque accumulation and inflammation, which in turn, may result in bone loss, marginal tissue recession, and peri-implantitis, we better understand the valuable role that soft tissue grafts can play in protecting implants and developing the pink esthetics.1 Studies have shown a reduced risk of marginal tissue recession and improved esthetic outcomes when connective tissue grafts were combined with immediate implant placement in the esthetic zone.2
To be successful long term, each implant requires sufficient vertical and horizontal tissue thickness. An adequate width of keratinized gingiva is necessary on both the buccal and lingual aspects. Furthermore, sufficient vestibular depth with a lack of frenum attachments and/or muscle pull is crucial for tissue stability. Fortunately, we have multiple opportunities to address the soft tissues during the different treatment phases of implant therapy. Soft-tissue management can be implemented before implant placement, at the time of implant placement, during the second stage of two-stage implant surgery, or after implant restoration.3 However, cases that present with severe bone and tissue deficiency may require multiple soft-tissue management procedures to be implemented at different phases of treatment.
The preferred time to address soft-tissue deficiencies is during the second stage of implant surgery because that is when the clinician is able to best visualize and diagnose their type and location. Moreover, this is a stage in which a surgical procedure is already being performed, so utilizing it for soft-tissue management can help to reduce the overall number of surgeries that a patient is required to undergo. Conversely, performing soft-tissue grafting around implants that have already been restored can be cumbersome and risky; therefore, every attempt should be made to address tissue deficiencies before final restoration.
This article presents two case reports that demonstrate how different soft-tissue grafting techniques may be applied during the various phases of implant therapy.
Case Report 1
Four months after undergoing the extraction of tooth No. 6 and a ridge preservation procedure, a patient presented for implant placement. The ridge width, however, was mildly deficient (Figure 1). Although sufficient bone is necessary around implants, it is the soft tissue that provides the necessary tissue bulk for proper pink esthetics. The site was managed with implant placement (AnyRidge®, MegaGen) (Figure 2) and a simultaneous guided bone regeneration procedure using an allograft (MinerOss® Cortical & Cancellous, BioHorizons) and a collagen membrane (Mem-Lok®, BioHorizons). In addition, a connective tissue graft was harvested from the palate and layered over the collagen membrane. Periosteal sutures were then utilized to stabilize everything in place (Figure 3) and primary closure was obtained (Figure 4). During the second stage of surgery, a punch incision was used to uncover the implant platform, and a vestibuloplasty procedure was performed on the buccal aspect of the ridge to eliminate any mucosal tissue pull (Figure 5). Four-weeks after temporization, the bulk of keratinized attached tissue that was created by the connective tissue graft can be visualized as well as the natural emergence profile that was established (Figure 6). The final restoration exhibited excellent soft-tissue esthetics that satisfied the patient (Figure 7).
Case Report 2
In cases involving bone augmentation, it is particularly important to recreate a buccal and lingual band of attached gingiva for long-term protection and stability. In this case, the patient presented for second-stage surgery following a healing period after vertical guided bone regeneration and staged implant placement (AnyRidge®, MegaGen) in the posterior left mandible (Figure 8). The keratinized gingiva present at the crest of the edentulous ridge was only 2-mm wide prior to uncovering the implants. To improve the thickness, the native keratinized gingiva was mobilized and repositioned toward the lingual aspect, and a vestibuloplasty procedure was completed on the buccal aspect to apically reposition the mucosa (Figure 9). Healing abutments were then placed, and a free gingival graft was harvested and sutured onto the buccal aspect (Figure 10). Six-weeks postoperatively, the recreated volume of attached gingiva on the buccal and lingual aspects can be visualized (Figure 11).
Soft-tissue management allows clinicians to put finishing touches on cases with esthetic deficiencies. Grafting techniques are essential not only to build tissue volume that is crucial for esthetics but also to recreate attached gingival tissues and vestibular depth that may have diminished during treatment. Knowledge and application of these principles is key to obtaining long-term bone and tissue stability.
Every dentist involved in any aspect of rehabilitation with dental implants should be knowledgeable and trained regarding peri-implant soft-tissue management. Surgeons should be well versed in soft-tissue management/grafting techniques that facilitate maintenance/recreation of the necessary quantity and quality of soft tissues, and restorative dentists should be well-versed in molding and shaping the soft tissue in order to develop proper implant emergence profiles. Soft-tissue management should not be viewed as a luxury that is only bestowed upon certain patients; it should be viewed as a necessity that is incorporated into every single implant case.
About the Author
Ehab Moussa, DDS, MSD
New Orleans, Louisiana
1. Kungsadalpipob K, Supanimitkul K, Manopattanasoontorn S, et al. The lack of keratinized mucosa is associated with poor peri-implant tissue health: a cross-sectional study. Int J Implant Dent. 2020;6:28. doi: 10.1186/s40729-020-00227-5.
2. De Angelis P, Manicone PF, Gasparini G, et al. Influence of immediate implant placement and provisionalization with or without soft tissue augmentation on hard and soft tissues in the esthetic zone: a one-year retrospective study. Biomed Res Int. 2021;2021:8822804.
3. Kadkhodazadeh M, Amid R, Kermani ME, et al. Timing of soft tissue management around dental implants: a suggested protocol. Gen Dent. 2017;65(3):50-56.