Papilla preserving modified roll technique for stage 2 soft tissue augmentation.

The aim of the article is to describe a modification of the roll flap, performed at the implant second surgical stage, allowing the correction of small horizontal defects by enhancing the soft-tissue thickness and improving the buccal soft-tissue profile. The advantages for this modification lies in the fact to preserve the papilla morphology and enhancement of the soft-tissue esthetic results.

INTRODUCTION

Collapse of the hard and soft-tissues occur following extraction and the severity of the horizontal and vertical loss of tissue may reach up to 60% after 2 years.[1234] Considerable volume of post extraction ridge loss is encountered in the 1st year of tooth loss. Absence of adequate buccal bone thickness attenuates the severity of the ridge loss. These localized ridge defects are characterized by regional deficit of bone and/gingival tissue. These defects may result from tooth extraction, local trauma, periodontal lesions, congenital developmental disturbances. Such defects present a challenge for implant placement, soft-tissue adaptation and finally prosthetic rehabilitation. Implant supported rehabilitation has the final goal of achieving a soft and hard tissue integrity with optimal esthetics. An accurate soft-tissue treatment may facilitate peri-implant soft-tissue stability over time.[5] Localized ridge defect can be due to either bone and or/soft-tissue deficit. Type 1 and 2 ridge defects (soft-tissue) have been shown to have a predictable success rate post augmentation.[6] The importance of a thick keratinized peri-implant mucosa has been indicated for prevention of mucosal recession and maintenance of peri-implant health. Various techniques to augment keratinized tissue on implant sites have been described in the literature: Roll flap, connective graft, epithelial and connective graft, coronally advanced flap.[7] This case report presents a surgical modification of the “Roll Technique” in the management of deficient soft-tissue around the implants. At 2 years follow-up, after the prosthesis presented a stable peri-implant tissue.

CASE REPORT

The present case report is about two patients age group 23-32 years presented with an edentulous space in relation to 22, 23. After successful placement of the implant, clinical presentation as after 4 months was: (1) Deficient buccolingual width (2) thin keratinized mucosa. (3) H-s class defect (horizontal defect ≤3mm).[8] Bone gauge was used to estimate the crestal bone thickness around the implant to rule out the hard tissue defect. Transgingival probing was done to measure the soft-tissue thickness before surgery with acrylic stent and graded periodontal probe in millimeters (mm) with a rubber stop. Soft-tissue augmentation was planned to improve the buccal tissue thickness around the future implant supported prosthesis.

Surgical technique

After procuring adequate anesthesia, pedicle flap was outlined starting as partial thickness horizontal incision 3-4 mm away from diameter of the underlying cover screw from the palatal side. Two vertical partial thickness incisions, 1.5 mm away from the adjacent interdental papilla, were marked out from the horizontal incision up to the crest and descended buccally. The length of the vertical incision corresponding to the length of the pedicle flap. The palatal tissue was marked and de-epithelized. Partial thickness pedicle flap was reflected palatally. On approaching the crest over the cover screw, it was further reflected as a full thickness flap extending buccally to create a pouch dissection with the buccal periosteum intact. Once the buccal dissection was complete, the palatal tissue of the pedicle graft was rolled and tucked into the buccal pouch. The rolled pedicle flap was meticulously sutured around the emerging implant using cytoplast sutures. (4-0) (Cytogenix) and silk sutures (5-0, Ethicon) 3 mm high healing abutments were screwed - in to provide support for the rolled pedicle graft [Figures 1–13] schematic representation of the surgical steps. Post-surgical instructions were given. Oral antiseptic rinse (0.12% chlorhexidine) twice a day for 4 weeks and analgesic (ibuprofen) 8 hourly for 5 days was prescribed. At 5 weeks, sutures were removed. Impressions were made and temporary crowns cemented maintaining a long contact point. After intermediate healing period of 10 months, final prosthesis was placed [Figure 7].

Figure 1

Pre-operative thin keratinized mucosa

Figure 13

Rolled flap into the buccal pouch and sutured

Figure 7

Final prosthesis in place

De-epithelised palatal donor site

Papilla saving incision and reflection of partial thickness palatal flap

Suturing of the rolled palatal flap into the buccal pouch

5 week follow up with temporary abutments in place

Temporary crowns cemented

De-epithelization of the donor site

Papilla saving incisions marked

Partial thickness palatal incisions

Partial thickness flap raised

Creation of the buccal pouch

Mean mucosal thickness as achieved after 2 years was 2.6 mm and mean increase in thickness was 1.75 mm [Table 1].

Table 1

Thickness of the keratinized tissue (in mm) at baseline and at 2 years

DISCUSSION

Bone resorption is irreversible, chronic and cumulative. Approximately two-thirds of bone width resorption occurs within the first 3 months after tooth extraction. In the maxillary frontal region, the resorption is characterized by a marked horizontal component and variable amount of vertical deficit. Any alteration in the gingival morphology post extraction plays a vital role in determining the final esthetic outcome. These localized ridge deformities used to be corrected with prosthetic materials in order to reestablish the natural arch contour. These prosthesis were acceptable from a functional viewpoint but resulted in poor esthetics. With the advent of periodontal plastic surgical procedures and their successful performance in implantology has helped in restoring the ridge deformities before, during and after implant placement.

Mucosal biotype is an important factor for a successful esthetic – treatment outcome. A thin biotype has less interdental papilla fill with increased risk of peri-implant recession.[9] In a study by Chung et al. observed that mucosal inflammation and plaque accumulation were significantly higher around implants with KM <2 mm.[10] Thick mucosa (≥1 mm) is associated with less mucosal recession as compared with a thin mucosa (<1 mm).[11]

Cardaripolli in a prospective study measured the dimensional alterations of the soft and hard tissues around 11 single-implant restorations over a 1-year postloading period. 1.3 mm of buccal and lingual bone loss was reported. The corresponding mean soft tissue loss was 0.6 mm. The observed changes however were within 4 weeks of implant uncovery and before prosthesis.[12] The degree of mucosal collapse depend on the biotypes of the peri-implant mucosa. Hence the need to transform a thin mucosal biotype to a thick keratinized tissue is vital in order to have stable periimplant dimensions.

Free mucosal graft and free connective tissue grafts have been used to augment the soft tissues around the implant. These grafts are harvested from the palate of the same patient and transferred to the recipient site. In the aesthetic zone it is usually necessary to provide a band of keratinized gingiva in order to harmonize with the surrounding adjacent natural teeth. Connective tissue graft with a collar of epithelium attached will achieve the desired result. The results of the pediculated connective tissue graft with its rich vascular supply helps in augmenting and thickening of the marginal tissue better than the free connective tissue graft.

Achieving and maintaining an adequate marginal gingiva thickness and sufficient width of keratinized tissue at an early phase of the implant uncovery surgery is important for the maintenance of peri-implant health and esthetics.

Speroni in a 3 year retrospective study on the augmented soft-tissue observed a mean mucosal thickness of 2.89 mm and mean increase in mucosal thickness of 1.75 mm at 12 months when compared from baseline.[13] This case report has presented a modified roll technique for soft-tissue augmentation around a dental implant during the second stage of implant surgery. Primary goal was to correct a mild to moderate buccal ridge deficiency. The mean mucosal thickness as achieved after 2 years was 2.6 mm and mean increase in thickness as 1.75 mm from baseline. The advantage of this technique resulted in preserving the interproximal tissue, less discomfort and faster healing of the palatal donor site.

And enhance the marginal gingiva associated with the dental implant.

In a systemic review on surgical procedures for soft tissue augmentation, all autogenous tissue graft procedures were found to be effective in increasing tissue volume. No one technique was found to be superior to others.[14] It would therefore appear that treatment success is not a function of the choice of a surgical technique and the choice of a specific surgical technique is not as important as the adherence to sound biologic principles. If the aim is to achieve a good clinical outcome.

CONCLUSIONS

The procedure as describe in this case report is indicated for correction of mild to moderate buccal ridge deficiency or to increase the bulk of the marginal gingiva at the stage two implant surgery. Average increase in the mucosal thickness was 2.5 mm and increase in keratinized tissue was up to 1.8 mm in both the cases after 2 years post loading. This procedure provided a good healing and stability of the peri-implant tissues after the maturation time of the soft-tissue augmentation.