Clinical
ABOUT THE AUTHORS
Donald Morrison, owner and partner of Quadrant Dental Practice, gained his BDS from Dundee University in 1997. He has trained extensively with experts worldwide, as well as holding a Master’s in Aesthetic Implant
Dentistry from the University of Lancashire. Donald takes great pleasure in working with ground- breaking dental techniques to provide excellence in treatment for patients using a gentle and caring approach that is second to none.
Peter Byrne, owner and partner of Quadrant Dental Prac- tice, qualified from Glasgow Dental School. He too has trained exten- sively with
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given to performing flapless surgery or immediate implant placement to maintain the soft tissue support. The flapless approach or using tissue punches have the advantage of reducing morbidity and speeding up soft tissue healing. Additionally, as no bone is exposed and periosteal blood flow is not compromised, it can lead to reduced bony resorp- tion and minimal soft tissue scar formation. The major drawback of this technique is poor surgical site visualisation and potential disposal of useful keratinised soft tissue. Where the buccal plate requires
visualisation, the choice is to preserve or lift the adjacent interdental papillae. Sclar (2003) describes the papillae preservation flap that allows for the adjacent papillae to remain over the inter- dental bone, with the relieving incisions curved and changing direction within the mucogingival border to disguise post-operative scar tissue. When significant ridge grafting
experts around the globe and also holds his Master’s degree in Aesthetic Implant Dentistry. His work ranges from single tooth replacements to complex full-mouth rehabilita-
tions, involving implants and cosmetic
dentistry using metal free- restorations.
is required, larger soft tissue flaps involving one or more adjacent teeth may be employed. Gener- ally with large flaps, relieving incisions are made distal to the anterior teeth. Care must be taken with these large flaps to minimise papillae recession post-operative bone resorption caused through tissue acidosis. Furthermore, signifi- cant flap advancement can result in transposition of unkeratinised sulcular epithelium over the neck of the implant, requiring corrective surgery later. There are many more novel solu-
tions to flap design that are case specific, such as the ‘aesthetic buccal flap’ described by Steigman (2008). In cases where periodontal bone support is poor but soft tissue archi- tecture is favourable, access to the buccal plate can be made through an incision in the mucogingival border without the need to interrupt or cut circumferential gingival fibres at the cervical margin.
Surgical staging, temporisation and immediate placement As discussed, if hard and soft tissue is optimised pre-extraction, and if there is no infection or occlusal issues, then considera- tion can be given to immediate
60 Scottish Dental magazine
Fig 3a
Fig 4a
Fig 3b
Fig 4b
Fig 3c
Fig 4c
Figs 3a-c: Four periodontally-involved upper incisors are a-traumatically extracted and sockets augmented with MinerOss particulate allograft and Mem-Lok membrane (BioHorizons Al) Note the interdental papillae mainte- nance after four weeks
Figs 4a-c: Missing inter-implant papilla. The implants are covered with a palatal sliding flap and re-exposed six weeks later with CTG to rebuild the papillae and improve tissue keratinisation
implant placement with immediate provisionalisation. It is difficult to provide a truly non-functional implant-retained temporary crown or bridge; however, a customised healing collar offers sufficient support to the facial and interdental soft tissues where loading is a concern. Surface modification on healing collars and abutments (Laser-Lok, BioHorizons) can also maintain soft tissue compartmentalisation by reducing apical migration of the junctional epitheilium, al lowing direct connet ive attachment to the collar/abutment itself (Nevins, 20ı0). In cases of keratinisation defi-
ciency, a submerged approach can be used to increase soft tissue bulk, allowing an attached connective tissue roll graft procedure during second stage surgery. In addition, submerging healing collars can allow for additional soft tissue ‘dead space’, as described by Salama (ı995), facilitating soft tissue manip- ulation at the restorative stages to guide tissue regeneration. Care must be taken when remov-
able temporisation is employed, due to the lack of papillary support and
possible tissue compression of the gingival architecture. If possible, adhesive temporary bridgework is preferable over an acrylic denture to replace bound saddles of less than 4 units. If a removable pros- thesis cannot be avoided, the functional compressive elements of pontic design overlying the implant must be sympathetically handled. Both removable and fixed solutions can help with pontic site develop- ment of soft tissue guidance prior to restoration.
Soft tissue augmentation During placement, the opportunity can be taken to augment the facial tissues to reduce repeated surgical intervention and morbidity by performing a free CTG from either the patient or cadaver sources.
Post-restorative management Post-restorative soft tissue correc- tion is the most common and least predictable soft tissue intervention. The restoration can be removed and soft tissue bulk improved if the implant position is favour- able. CTG can be employed to ‘biotype boost’ deficient soft tissue, although there is little evidence
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