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.
At the end of the chapter, the reader should be able to:
Determine when to graft or when to remove implants.
Treat tissue defects on the buccal surface of the implant.
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).
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.
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).
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).