Surgical & Prosthetic Options to Enhance Implant Soft Tissue Aesthetics
Over the past 20 years, implant dentistry in this country has evolved from a strictly overdenture discipline to a multi-tooth and single-tooth replacement option. Indeed, it is more than an option; it has become the standard of care for replacement of missing teeth. Improved office-based bone grafting and bone preservation techniques have greatly expanded the patient pool of implant candidates. However, it is no longer sufficient to simply provide enough bone for an implant to be placed prosthetically, it is now desirable in aesthetic areas to try to create ideal soft tissue architecture around these restorations. This can be done in a number of ways including soft tissue site preservation, soft tissue augmentation procedures, and via a prosthetic means.
Soft tissue site preservation is most often accomplished by the implant surgeon. This includes papilla sparing beveled cosmetic incisions when incisions are indicated for implant placement. In many instances, implants can be placed with no incisions in aesthetic areas using tissue punches to create the access for site preparation and implant placement, in fact, the tissue can be punched eccentrically toward the palate and if a single stage implant system is placed, the healing cap can be used to push extra attached tissue labially and provide increased soft tissue bulk along the labial aspect of the future restoration. Finally, in staged implant procedures where an implant is uncovered and a healing abutment or temporary placed, incisions can be designed at the second stage to allow tissue rotation to form papilla or to bulk-up tissue labially.
Soft tissue augmentation procedures include the subepithelial connective graft which is harvested in split thickness fashion from the patient’s palate. This allows linear closure of the palatal harvest site with no exposed tissue and a very comfortable surgery for the patient. When greater bulk is needed, vascularized palatal rotational subepithelial flaps can be employed. These are best employed in the anterior maxillary region and allow a large bulk of tissue to be rotated in similar fashion to the technique used for subepithelial connective tissue grafts, but the graft is not completely detached from its base, allowing it to maintain a good blood supply. Finally, a material such as AlloDerm®, a donated processed human dermis, can be used in many instances to perform gingival grafting or augmentation procedures,
Finally, and perhaps most importantly, prosthetic means exist for optimizing soft tissue architecture around implants. When an implant is to be placed at an edentulous space, or an extraction is to be performed and it is deemed undesirable to place an immediate implant; a well-designed flipper partial denture or a resin-bonded temporary can be used. This will include an ovate pontic set down into the tissue to help create an emergence profile for the future implant, as well as to promote the development of the interdental papilla. Then, at the time of implant placement, using a tissue punch, these papillae can be maintained and an implant can be performed. In some instances, an anterior tooth can be replaced with an implant and an immediate provisional can be fabricated. One clear advantage of this has to do with the positive effects of a well-designed temporary restoration on the soft tissue architecture and papilla around the implant restoration.
Additionally, well-designed temporaries and final restorations with proper emergence profiles dictate soft tissue architecture and papillary health for the long-term. The ability of the restorative dentist to achieve proper emergence profiles and contour of the restorations is predicated on the surgeon having placed the implant in the proper location, to the proper depth, and at the proper angulation.