330987815 soft-tissues-remodeling-technique-as-a-n-1-pdf

CLINICAL APPLICATION

2THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

VOLUME 7 • NUMBER 1 • SPRING 2012

Soft Tissues Remodeling Technique

as a Non-Invasive Alternative to

Second Implant Surgery

Xavier Vela, MD, DDS

Private Practice in Barcelona, Spain

Víctor Méndez, DDS

Private Practice in Barcelona and Madrid, Spain

Xavier Rodríguez, MD, PhD

Private Practice in Barcelona and Madrid, Spain

Maribel Segalà, MD, DDS

Private Practice in Barcelona, Spain

Jaime A. Gil, MD, DDS, PhD

Chairman of Prosthodontic, University of The Basque Country,

Bilbao, Spain

Correspondance to: Dr Xavier Vela

Barcelona Osseointegration Research Group, Sant Martí 43-47, Sant Celoni 08470, Barcelona, Spain;

Tel: +34-938-675822; Fax: +34-938-674419; E-mail: [email protected]

VELA ET AL



Abstract

It is currently accepted that success in

implant-supported restorations is based

not only on osseointegration, but also on

achieving the esthetic outcome of natu-

ral teeth and healthy soft tissues. The so-

called “pink esthetics” has become the

main challenge in the implant-supported

rehabilitations in the anterior area. This is

especially difficult in the cases with two

adjacent implants.

Two components affect the final peri-

implant gingiva: a correct bone support,

and a sufficient quantity and quality of

soft tissues. Several papers have em-

phasized the need to regenerate and

preserve the bone after extractions, or

after the exposure of the implants to the

oral environment. The classical implanta-

tion protocol entails entering the working

area several times and always involves

the surgical manipulation of peri-implant

tissues. Careful surgical handling of the

soft tissues when exposing the implants

and placing the healing abutments (sec-

ond surgery) helps the clinician to obtain

the best possible results, but even so

there is a loss of volume of the tissues

as they become weaker and more rigid

after each procedure.

The present study proposes a new

protocol that includes the connective

tissue graft placement and the soft tis-

sues remodeling technique, which is

based on the use of the ovoid pontics.

This technique may help to minimize the

logical scar reaction after the second

surgery and to improve the final emer-

gence profile.

(Eur J Esthet Dent 2012;7:xxx–xxx)






Introduction

It is currently accepted that success in

implant-supported restorations is based

not only on osseointegration, but also on

achieving the esthetic outcome of natu-

ral teeth and healthy soft tissues.

Over recent years, a large number of

papers have focused on the so-called

“pink esthetic”, and the majority of au-

thors agree that it is difficult to ensure

that the gingiva around the implant-

supported restorations has the same

thickness and height as is found around

natural teeth. This is especially difficult

in the interimplant papilla, which is now

one of the greatest challenges in esthet-

ic implant dentistry.1,2

Several papers have emphasized the

need to preserve the bone after extrac-

tions or to regenerate the lost bone be-

fore or during the implant-placement.

The bone not only fixes the implant but

also plays an esthetic role, giving sup-

port to the soft tissues.3

Nowadays the classical protocol pro-

posed by Branemark4 continues to be

useful and predictable. Three surgical

steps compose this protocol: the extrac-

tions, the implant placement and some

months later, the second surgery, when

the implant becomes exposed to the

oral environment.

This second surgery usually means

peri-implant bone resorption because of

the biologic width establishment5,6 and

also a soft tissue scar reaction, which is

especially important in a case with two

adjacent implants, taking into considera-

tion the limitations to obtain an adequate

height of the interimplant papilla.7

The present study proposes the gin-

gival remodeling technique as a way to

obtain a predictable interimplant papilla

and avoid a traumatic second surgery.

Gingival remodeling

To achieve a good prosthetic emer-

gence profile, several of the surgical

techniques that have been described

can be used in the different stages of an

implant treatment.8–11

Careful surgical handling of the soft

tissues when exposing the implants and

placing the healing abutments (second

surgery), helps with obtaining the best

possible results.12 But even so, there is a

loss of volume of the tissues as they be-

come weaker and more rigid after each

procedure.2

To prevent surgery causing side ef-

fects in the soft tissues, the present study

proposes a new protocol that includes

the technique of soft tissue remodeling,

minimizing the logical scar reaction after

the second surgery and the loss of qual-

ity and quantity of the inter-implant soft

tissues. This new protocol involves two

steps:

1st stage – the connective tissue graft placement

The function of the epithelium is to pro-

tect the internal medium from the ex-

ternal contaminated environment. The

connective tissue gives support, filling,

nutrition, and defense. To ensure these

functions, the connective tissue is com-

posed of several collagen fibbers, posi-

tioned in different directions.13

The first two functions are the ones that

will help us most in improving our esthetic

outcome, conditioning not only the gingi-

VELA ET AL



Fig 1 Adding compomers to the temporary tooth-

supported bridge. (a) First week (b) Second week

(c) Third week (d) Fourth week

val volume but also the response of this

tissue to prosthetic manipulations and

even preventing chromatic alterations.14

As it is possible to adapt and mold

this component to the shape of the tem-

porary prostheses, the connective tis-

sue will determine the so-called pink

esthetics of the implant supported re-

habilitations, which plays an important

role in the final prosthetic result. For this

reason, especially in the esthetic zone, it

is essential to achieve a good thickness

of moldable connective tissue.

Several techniques have been pro-

posed to increase the connective tissue

thickness, depending on the protocol,

the placement of the graft when simul-

taneously seating the implants in the ini-

tial surgical stage; and more recently the

type of incision, the location of the donor

site, the volume susceptible to earn.15-17

One of the most used procedures is

the subepithelial connective tissue graft

technique, proposed by Langer and Ca-

lagna.15 The soft tissue graft is placed at

a different surgical stage to the implant

site, because in the esthetic zone it is

usual to augment the bone when plac-

ing the implants. This implies the use

of biomaterials and resorbable mem-

branes, so reducing the vascularization

of the recipient site and increasing the

risk of necrosis.18

2nd stage: the modeling of the augmented soft tissues through the ovate pontics of the tempo-rary prostheses

The use of ovate pontics has been wide-

ly described. Pressure is put on the soft

tissues to obtain the ideal emergence

profile.19-23

The present technique takes this con-

cept further, finishing when the ovate

pontic makes contact with the cover

screw. Then, it can be replaced by a

healing abutment, thus avoiding a trau-

matic second surgery. This can be done

using temporary prosthesis.24,25

There are two possible options:

�� If it has been decided to use neigh-

boring teeth as part of the restorative

treatment, then temporary tooth-sup-

ported bridges will be used (Fig 1).

�� If neighboring teeth will not be in-

volved in the treatment, a removable

partial skeletal prosthesis is suggest-

ed (Fig 2), which will guarantee pros-

thetic stability. The prosthesis can

be the same as the one the patient

has been wearing over the previous

months since the exodontia, and

will subsequently be used to help

achieve an optimal esthetic result.

a

c

b

d




This type of partial prosthesis is less

comfortable for the patient, but has

the advantage of easy access and

manipulation, and does not involve

aggression to neighboring teeth.

The pontic should be placed at a slight

distance from the gingiva during the first

few weeks so it will not exert pressure on

the grafts, which could compromise their

vascularization and cause necrosis.

The soft tissue remodeling starts one

month after the soft tissue graft place-

ment. Nonetheless, fluoroangiographic

studies by Busschop et al show that

grafts are fully revascularized after 15

days; therefore, it could be possible to

start gingival remodeling even sooner.26

The ovate pontics volume of the tem-

porary prostheses gradually increases

week after week, adding an easy-to-

handle light-cured biocompatible mate-

rial: compomers. The compomers have

shown their biocompatibility in class V

restorations, where the compomer is in

contact with the gingiva.

The changes of the shape and the en-

largement of the volume, lead the ovate

pontics to mold the gingival, gradually

achieving the ideal emergence profile

(Figs 3 to 5). The pressure on the soft

tissues must not be harmful, because

the epithelium must preserve its integrity

and the connective tissue has to recover

its normal vascularization after only a few

minutes of ischemia. For this reason the

increased volume should not be greater

than 1–1.5 mm per week.

The shape and volume of the ovate

pontics must be adapted to the needs of

the each particular case, and the weekly

changes of the temporary prostheses

have to be adapted to the evolution of

the soft tissues. This means that there

is not a pattern that marks the design

of this technique. The surgical guide

used for the correct positioning of the

implants can help to guide the change

in the shape and volume of the ovate

pontics in order to reach the implants.

The objective of this technique is not

only to achieve the ideal emergence pro-

file but also to avoid a traumatic second

surgery. This means that the process

should be followed for four or five weeks

until the cover screws are exposed.

At the end of the process, only a thin

epithelium layer is covering the cover

Fig 2 (a) Adding compomers to the removable partial skeletal prostheses. (b) First week (c) Second

week (d) Third week (e) Fourth week

ba c d e

VELA ET AL



Fig 3 Soft tissues remodeling technique. Clinical case with removable temporary prostheses. (a) Initial

situation (b) Stage 1. Immediate implant placement after extraction before hard and soft tissues grafts. (c) Stage 2. Two months after implant placement, here starts the soft tissue remodeling technique. (d) One

week later (e) Two weeks later (f) Three weeks later. Notice the implant transparency in the occlusal view

(right). (g) Four weeks later: non-invasive second stage, impression copying test. (h–i) One year after the

prosthetic placement and Rx.

a b

c

e

g

d

f

h

i




Fig 4 Soft tissues remodeling technique. Clinical case with removable temporary prostheses. (a–b) Initial situation (c) Stage 1 – delayed implant placement and hard and soft tissue grafts. (d) Stage 2 – six

months later. Here starts the soft tissue remodeling technique. (e) One week later (f) Two weeks later (g) Three weeks later (h–i) Four weeks later. Non-invasive second stage. (j–k) One year after the prosthetic

placement.

a b

c

e

g

d

f

h

i

k

j

VELA ET AL



Fig 5 Soft tissues remodeling technique. (a) Clinical case with fixed temporary prostheses. (b) Stage

1 – implant placement with hard and soft tissue grafts. (c) Fixed temporary prostheses. (d) Stage 2 – six

months later. The soft tissue remodeling technique begins. (e) One week later (f) Two weeks later (g) Three weeks later (h) Four weeks later – the non-invasive second stage. (i–j) Two years after the prosthetic

placement.

a b

c

e

g

d

f

h

j

i




screw. A screwdriver is usually enough

to pierce the epithelium, remove the

cover screw and place the healing abut-

ment or the impression coping.

This two-stages technique avoids the

second surgery, which would possibly

damage the interimplant papilla, prob-

ably the most sensitive area, and deter-

mines the final outcome in a case with

adjacent implants.

Discussion

According to literature, the most difficult

area to obtain an adequate height of the

papilla is the interimplant space. Some

papers agree that the average height of

the interimplant papilla, measured from

the contact point to the interimplant

bone peak, is 3.5 mm compared to the

6.5 mm found between natural teeth.7

Therefore, independently of bone lev-

el, the interimplant papilla always has

a lower height, and this conditions the

esthetic outcome when comparing it to

the height of the soft tissues between

natural teeth.7,27,28

With this in mind, it seems of para-

mount importance to maintain the inter-

implant bone peak, trying to minimize

the peri-implant bone resorption after

expositing the implants to the oral envi-

ronment. The new concept of platform

switching has led to a considerable re-

duction in peri-implant bone loss with

average bone loss values of 0.65 mm

on the vertical and horizontal axis.29–32

The exposure of the implants to the

oral environment has been related to

peri-implant bone resorption and the

soft tissues retraction. Some authors

have described the soft tissues around

the implant abutments as a scar with

abundant collagen fibers and few cells.

Berglundh et al33 observed that the vas-

cular supply in the free gingiva comes

mainly from the supraperiosteal vessels

and the vessels of the periodontal liga-

ment (Figs 3–5).

However the vascular system in the

peri-implant mucosa originates solely in

the large supraperiosteal blood vessel

outside the alveolar flange. This vessel

branches to form a plexus of capillaries

and venules under the oral epithelium

and the junctional epithelium. The authors

reported that there is no vascular plexus

near the implant to compensate for the

lack of the periodontal ligament plexus.

Lindhe et al reported a diminished de-

fensive capacity of the peri-implant gin-

giva as compared to the periodontal gin-

giva.34 This compromised situation was

largely explained by the vascular deficit

in the supra-alveolar connective tissue.

Thus, there is a considerable limitation

of the peri-implant soft tissues healing

in front of an aggression, eg, such as

a surgical aggression. For this reason

it seems interesting to avoid a second

surgery, especially when there are two

adjacent implants in the esthetic zone.

The surgical treatment to expose the

implants implies an open wound. The

second intention healing causes the

contraction of the tissues to reduce the

gap between the abutment and the mu-

cosa and the new epithelization guaran-

tees the closure of the exposed tissues.

These tissue reactions are particularly

important when they affect the inter-

implant tissues between two adjacent

implants, causing an important loss of

quantity and quality of the inter-implant

papilla.

VELA ET AL



The present technique described in

this article is able to reduce the scar re-

action of the peri-implant tissues. This

technique is based on the use of the

ovate pontics. The ovate pontics modify

the shape of the residual ridge by grad-

ual pressure over the gingival tissue,

improving esthetics and giving a natu-

ral look to our restorations.35 A gradual,

controlled hyperpressure can transform

an unfavorable tissue configuration. This

allowed a more natural, functional resto-

ration. There is also a possibility of clos-

ing undesirable ‘black holes’ through pa-

pilla ‘formation’, by pressuring the tissue.

In the past, some believed that a pres-

sure over the residual ridge resulted in

an inflammatory process. Recently pub-

lished data have shown that a well con-

trolled hyperpressure, applied with a

convex and highly polished pontic, asso-

ciated with rigid plaque control, resulted

in only a thinning of the epithelium with no

inflammation.35 Tripodakis and Constan-

tinides36 showed that increased pres-

sure from smooth, polished, and glazed

convex pontics in patients with excellent

plaque control did not induce inflamma-

tion in the adjacent tissues. Tolboe et al37

demonstrated that the mucosa under

ovate pontics remained healthy, irrespec-

tive of the pontic material used, when

dental floss was used regularly. Zitzmann

et al38 performed a histological evaluation

of the alveolar ridge mucosa adjacent to

an ovate pontic after 1 year, showing that

these sites were not associated with overt

clinical signs of inflammation.

The ovate pontics move the connective

tissue and the epithelium progressively

without damaging them. The pressure

does not break the epithelial barrier but

it moves it onto the cover screw. The final

healing after removing the cover screw

and placing the healing abutments has

only to cover a minimum distance to en-

sure the biologic width establishment. A

better vascularization of the peri-implant

soft tissues and less scar reactions could

be the consequence. Few changes oc-

cur after the exposure of the implants and

the gingival architecture remains similar.

A minimum thickness of 3 to 5 mm of

soft tissue is required to improve the final

outcome.35 This measurement is record-

ed from the gingival crest to the alveolar

ridge. Optimal results are realized when

pressure is applied to thick tissues, al-

though caution is needed regarding

its resilience.35 For this reason, soft tis-

sue augmentation through subepithelial

connective tissue grafts is commonly

required before starting the soft tissue

remodeling technique.

Conclusions

The use of this technique can reduce the

scar reaction of the soft tissues, which is

usually caused by the second surgery to

expose the implants to the oral environ-

ment. This effect is especially important

in the interimplant papilla of adjacent im-

plants in the anterior area.

The pressure of the ovate pontics

move the soft tissue, thus achieving an

optimum emergence profile and main-

tain the integrity of contact between the

epithelial barrier and the cover screw,

so avoiding a traumatic second surgery.

This study concludes that the soft

tissue remodeling technique based on

the use of the ovate pontics can help to

improve the esthetic outcome, and the

predictability of these cases.




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