1. INTRODUCTION
The appearance of the soft tissue in the anterior region after osseointegration and placement of the definitive prosthesis reflects the quality of the planning and execution of the surgical and prosthetic procedures. Failures in the transition zone between prosthesis and implant usually represent inadequate biologic integration among tissues or errors in implant positioning.
The dilemma is to maintain or remove an osseointegrated implant. Implants placed in the ideal three-dimensional (3D) position and presenting tissue deficiencies due to the absence or failure of a graft or long-term tissue remodeling can be treated with surgery to recover the lost tissue.
Poorly placed implants, resulting from technical errors at the time of the surgery or insufficient bone tissue for their optimal positioning, should be removed if the patient has esthetic complaints or pathological changes. This presents a challenging situation for the patient since it involves returning to a toothless condition as well as financial, time, and biologic costs.
Implant removal instead of a bone or gingival graft in esthetic areas occurs because of lack of space for the peri-implant tissues (soft and hard). Grafts in areas with poorly positioned implants will not solve esthetic complications but may aid peri-implant health.
In general, mucogingival procedures can be performed around implants to increase the band of attached gingiva and tissue volume. For the loss of papillae or recession around implants, it is necessary to combine orthodontic or restorative and surgical procedures.
OBJECTIVES
At the end of the chapter, the reader should be able to:
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Determine when to graft or when to remove implants.
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Treat tissue defects on the buccal surface of the implant.
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Establish the best way to treat papillary defects around implants.
2. SCIENTIFIC BACKGROUNG
Esthetically pleasing and functional outcomes result from an adequate quantity and quality of peri-implant tissues1. During treatment with implants, tissue manipulation promotes an adequate transition zone.
After osseointegration and healing of the grafts, adequate peri-implant tissues are expected. The provisional prosthesis will condition and maintain the tissue before a definitive prosthesis is made2 (Figs 01A–D).
01. A–D After osseointegration and tissue conditioning in multiple or single rehabilitations, the tissue may present an adequate (A, C) or inadequate contour (B, D).
It is common for esthetic complaints to occur after the final prostheses and implants are placed. At this time, dealing with these defects is a challenge, especially if the implant is not in the ideal position3. Although minor corrections are predictable, major defects require more than just surgical methods.
Soft tissue grafts can be used for a thickness gain of less than 2 mm, for fenestrations, or recessions4.
Bone grafts can be used for bone fenestration or dehiscence or defects from the progression of peri-implant disease. These interventions should be made before placement of the final prosthesis5–7.
2.1. TISSUE MANIPULATION AROUND OSSEOINTEGRATED IMPLANTS
2.1.1. SUBMERGED IMPLANTS
If the site presents volume deficiencies and the implant is submerged, techniques to increase volume at the time of reopening can be performed. A simple lingual incision, aimed at displacing the flap to the buccal or a subepithelial connective tissue graft can be done. The graft may be sutured to the buccal flap, palatal flap (around the healing abutment), or to the healing abutment itself (Figs 02A–L and 03A–F).
02. A–L Implant installed on tooth 24 with volume deficiency and narrow band of attached gingiva (A). A more lingual incision was made and the flap was shifted to the buccal to increase tissue volume and the amount of attached gingiva (B). Then a thick connective tissue graft was removed from the tuberosity (C–I). The graft was placed in the appropriate position and the graft was sutured to the healing abutment itself. The graft was placed to verify its most appropriate positioning, with fixation of the graft to the planned healing path (J–K). The graft was punctured with a disposable irrigation needle to create a space for insertion of a tipped instrument (such as a dissector) (L).
03. A–F The graft fenestration was extended with the instrument itself and a narrow healing abutment was used to fix the graft to the operated region (A–E). Final aspect of the region (F). Surgical procedure: Dr Mariana Gratz supervised by Dr Fausto Frizzera.
2.1.2. UNSUBMERGED IMPLANTS
Patients may have complaints regarding the appearance of soft tissue during the provisional phase or even after the definitive prosthesis is installed. In these situations, it is important to evaluate the condition of the soft and hard tissue around the implant. The patient should be informed about the limitations, risks, and treatment options before any type of interventionis performed8. To treat the present complication, it may be necessary to perform new restorative, orthodontic, and surgical procedures, especially if there is tissue loss (Figs 04A–C to 07A–R).
04. A–C Change in height, thickness, and color of the peri-implant mucosa in the region of tooth 21 (A). It is possible to improve the height and thickness of the tissue with a gingival graft as long as the implant is well positioned. The buccal region should be prepared to receive an internally positioned connective tissue graft (B, C).
05. A–I Defect in the region of tooth 21 without change in the height of the papillae. The prosthetic component must have a cervical undercontour (A, B). The facial tissue should be prepared using microelevators and microblades (C, D). A thick connective tissue graft should be inserted into the prepared region and sutured at the base of the mesial and distal papillae (E, F). A horizontal suture should be performed to coronally pull the flap and allow wound closure and defect resolution (G–I).
06. A–S A patient undergoing temporaries presented with a complaint regarding the contour of her gingival tissue (A, B). Two narrow implants had been installed in the region of teeth 7 and 10 due to tooth agenesis. The surgical planning involved clinical crown augmentation on the anterior teeth, with the exception of the the implant region, which received a connective tissue graft to increase gingival volume and coronal repositioning of the peri-implant margin. After removal of the provisionals, it was observed that both abutments were at different heights and had their ends at the gingival level (C–F). The abutments were inverted to keep a portion of the end of the 12th abutment exposed and to facilitate its veneering; the temporaries were then relined and worn in the cervical region (G–L). The clinical crown augmentation was performed on anterior teeth up to the level of the cementoenamel junction of the maxillary central incisors (M). The flap was detached, released, and a thick connective tissue graft was removed from the hard palate region using the two-incision technique (N–S).
07. A–R The epithelial component of the graft was excised with Castroviejo microscissors and the graft sutured in the palatal flap; the facial flap was repositioned coronally in the implant region (A–D). Three months after surgery (E–G), the restorative procedures to treat the black spaces were performed; they consisted of the re-anatomization of the interproximal contour of the provisional restorations and distal portion of the maxillary incisors (H–O)
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