Clinical


aesthetic zone Implants in the


Donald Morrison and Peter Byrne from Quadrant Dental Practice explore the soft tissue issues to overcome when placing implants


T


ooth replacement using endosseous implants has provided predict- able and stable results with good long-term


implant survival rates. However, the goal of implant treatment has evolved from achieving purely osseous fixation to providing an aesthetic, long-lasting restora- tion that seamlessly blends with the existing dentition. Therefore, factors such as the appearance of soft tissue are of utmost importance in order to achieve success, espe- cially in the aesthetic zone. All implant placements have


hard and soft tissue components, and correct management of these tissues during treatment planning will avoid a simple case becoming a complex case. Soft tissue management can be


separated into: • Pre-implant placement – often overlooked


• With implant placement – all implant placements involve some component


• Post-implant restoration – most often reactionary in nature.


Pre-implant soft tissue manage-


ment is generally the most simple approach and yet the most difficult treatment to sell to the patient. Pontic or implant site development surgery can help to produce excel- lent results but adds to treatment duration. It requires the patient to accept the concept of delayed placement when treatments are advertised in the general media as ‘immediate’.


Soft tissue assessment and keratinised mucosa It is good practice to document the


58 Scottish Dental magazine Fig 1a Both angled away to retain elastics Fig 1b Pontic is buccal to tissues


Fig 1c Pre-op


Figs 1a-d: Patient


presents with decoronated upper left central. Signif- icant gingival display and thin biotype. Modified Mar- yland bridge with J hook post was cemented with the use of orthodontic elastics the retained root was extruded increasing tissue height while provid- ing a fixed temporary appliance for the patient


Fig 1d Eight weeks post-op


pre-operative soft tissue situation, not only to manage patient expec- tations but also to avoid potential litigation if there is disagreement over the position of the final gingival margin.


Important factors include:


patient biotype; papillae height; pocketing; marginal height relative to adjacent teeth; and the patient’s smile line in relation to the soft tissues. The minimum amount of


keratinised gingivae required has been a controversial topic. Clinical evidence suggests that if good oral hygiene is performed, then little to no keratinisation is required to maintain fixation. However, clinical experience


over clinical evidence suggests that having thick keratinised tissue at the gingival margin makes the biological seal around the implant more effective and reduces long- term tissue recession.


Pre-implant placement soft tissue management Tissue augmentation should be considered at the treatment planning stage. Starting with the ideal soft tissue improves the predictability of hard tissue augmentation, as well as implant health. It is better to have too much tissue early that can be manipulated, rather than have to replace it when there is a deficit post-operatively.


Tooth extrusion In cases where the tooth is still present, orthodontic tooth extru- sion may be appropriate to advance not only the soft but hard tissues, including the problematic inter- dental height (Mantzikos, ı997). Classic fixed arch orthodontics are very effective however, novel use of adhesive bridge work can advance the tissues coronal prior to extraction. (Figs ıa-d)


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