Clinical
Fig 2b
Fig 2a
Extraction techniques/ socket preservation Socket preservation should be discussed with all patients prior to any extraction. At this stage, the condition of the hard and soft tissues and temporisation tech- niques has a significant effect on the final aesthetic and functional outcome around implants. In cases where immediate place-
ment is not appropriate, preserving the architecture of the underlying hard and soft tissues is paramount. Wherever possible, extractions should be bone preserving using a combination of periotomes, eleva- tors and gentle rotation rather than expansion. Multi-rooted teeth should be divided and piezo surgery used to remove palatal or lingual bone to facilitate extraction. Alter- natively, the ‘furrowing’ technique should be employed to avoid buccal plate trauma. The socket should be cleaned
and debrided to remove macro- scopic infection as far as possible and encouraged to bleed. It is good practice to map the buccal plate for deficiencies with a periodontal probe at this stage. Using the natural tooth crown as a pontic can be an effective solution to maintain the soft tissue structure. (Fig 2a-c) In the presence of significant
apical pathology, we maintain the soft tissue using collagen cones retained in the socket with a hori- zontal criss-cross mattress suture, promoting clot stabilisation and preventing ingression of soft tissue into the bony socket. This is normally left for six to ı2 weeks
before additional surgical proce- dures are carried out. If it is believed that the majority
of any apical pathology has been removed, augmentation of the remaining socket can be conducted using bone particulate material. Collagen cones are inserted into the socket and flattened underneath the margins of the socket and sutured into place, again with retaining horizontal mattress sutures to encourage epithelial growth across the socket and limit ingression into the graft. (Fig 3a-c) In addition, if there is a signifi-
cant lack of keratinised tissue prior to extraction or at presentation, it may be necessary to perform soft tissue augmentation prior to any hard tissue or implant procedure. A connective tissue graft (CTG) with split thickness flap may be used to increase keratinisation volume and allow tension-free primary closure if significant bony defects are to be repaired. (Figs 4a-c)
With implant place- ment/pre-restorative Implant design It is important that clinicians are aware of how the design features of the selected implant influence implant position, and hard and soft tissue outcomes. It has been accepted that most two-piece bone level implants will cause some hard tissue loss if placed at the level of the crest. However, some provisional evidence suggests that both macro- and microscopic design features may reduce, if not completely prevent, crestal bone loss. There
Fig 2c
Figs 2a-c: Patient has root frac- tured upper right central incisor. Has high smile line with significant gingival dis- play. Tooth is atraumatical- ly extracted, grafting ma- terial placed and natural crown
replaced as temporary pontic to preserve soft tissue architecture.
has also been evidence of direct connective tissue attachment to the implant neck, which will rede- fine the tissue compartments of the biological width around dental implants and create a soft tissue biological supra-crestal seal for the bone that previous implant designs lacked. (Fig 5a) There is also scope to utilise tissue level implants to protect the crestal bone.
Ideal 3D placement The final implant position within the arch relative to the neigh- bouring dentition has a significant effect on the long-term outcome and stability of the overlying soft and hard tissue form. Buser (2004) has described the ideal biological envelope that a bone level implant must sit on so as not to cause further bone and soft tissue resorption, while Tarnow (2003) details the expected papillary position relative to the interdental bone. (Fig 5b) The final 3D position of the
implant is far more predictable if placed using a restorative-focused surgical stent. This can be simplified further if a radiopaque restora- tive trial is captured intraorally using CBVT, so that both surgical and restorative approaches can be combined into a CBVT guided surgical stent.
Flap design It is the authors’ belief that, if there is adequate form and function of both hard and soft tissue prior to placement, consideration must be
Scottish Dental magazine 59 Continued »
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