Treatment Of Peri-implant Soft Tissue Defects: A Narrative .
Critical ReviewImplantodontologyTreatment of peri-implant soft tissuedefects: a narrative review(a)FAESA Centro Universitário, Dental School,Department of Clinical Dentistry. Vitória,ES, Brazil.(b)UniversidadeFederal de Uberlândia UFU, School of Dentistry, Department ofPeriodontology and Oral Implantology,Uberlândia, MG, Brazil.(c)Universidade Guarulhos – UnG,Department of Periodontology and OralImplantology, Dental Research Division,Guarulhos, SP, Brazil.Abstract: Soft tissue defects around dental implants, such as papillaor volume loss, peri-implant recession and alterations of the ridge colorand/or texture, lead to esthetic and functional complaints. Treatmentsof these defects in implants are more demanding than in teeth becauseperi-implant tissue exhibits different anatomical and histologicalcharacteristics. This narrative review discusses the proposed treatmentsfor soft tissue defects around implants in the current literature. Severalclinical and pre-clinical studies addressed methods to augmentthe quantity of the peri-implant keratinized mucosa. Autogenousgrafts performed better than soft tissue substitutes in the treatmentof soft tissue defects, but there is no clinical consensus on the moreappropriate donor area for connective tissue grafts. Treatment for facialvolume loss, alterations on the mucosa color or texture and shallowperi-implant recessions are more predictable than deep recessions andsites that present loss of papilla. Correction of peri-implant soft tissuedefects may be challenging, especially in areas that exhibit largerdefects and interproximal loss. Therefore, the regeneration of soft andhard tissues during implant treatment is important to prevent theoccurrence of these alterations.(d)Faculdade Ilapeo, School of Dentistry,Department of Dentistry, Curitiba, PR, Brazil.Keywords: Dental Implants; Esthetics; Therapy, Soft Tissue; Transplants.Fausto FRIZZERA(a)Guilherme José Pimentel Lopes deOLIVEIRA(b)Jamil Awad SHIBLI(c)Kely Cristina de MORAES(d)Eloísa Boeck MARCANTONIO(e)Elcio MARCANTONIO JUNIOR(f)(e)Centro Universitário de Araraquara –Uniara, School of Dentistry, Department ofDentistry , Araraquara, SP, Brazil.(f)Universidade Estadual Paulista – Unesp,School of Dentistry, Department of Diagnosisand Surgery, , Araraquara, SP, BrazilDeclaration of Interests: The authorscertify that they have no commercial orassociative interest that represents a conflictof interest in connection with the manuscript.Corresponding Author:Elcio Marcantonio JrE-mail: 3107bor-2019.vol33.0073Submitted: June 10, 2019Accepted for publication: June 13, 2019Last revision: June 19.2019IntroductionDental implants have been used for decades to treat tooth loss inseveral clinical situations.1 With a proper treatment plan, placement ofthe implant in the correct tridimensional position and reconstructionof the lost tissues produce satisfactory results that are maintained overtime.2 However, some esthetic and/or functional alterations may occurin the soft tissues that jeopardizes the success rate of these implants.2,3The alveolar ridge undergoes clinical and biological modificationsafter tooth extraction that result in soft and hard tissue loss. If no bonegraft is performed in an intact socket, a loss of approximately half ofthe socket volume may be expected, with major loss in the facial bonewall.4,5 Socket grafting may reduce the volume loss to 5–15% but the bonegraft itself cannot maintain the alveolar ridge volume in its plenitude.5,6Consequently, soft tissue grafts may be used to achieve better clinicalresults, compensate the alveolar ridge loss and provide a more stableperi-implant mucosa around implants.7Braz. Oral Res. 2019;33(suppl):e0731
Treatment of peri-implant soft tissue defects: a narrative reviewSome papilla loss around dental implants isexpected regardless of the type of implant placement,especially when several surgical procedures areperformed to rehabilitate a patient.8 This loss may bereduced by performing a flapless immediate implantand provisional placement, but approximately 0.5 mmof the papillae migrates apically.9 Reducing thesevalues facilitates the rehabilitation of patients becauseonly the tip of the papilla is compromised, and thefinal restoration contour provides an appropriateoutcome. The treatment of these alterations forgreater losses becomes more complicated, andone major consideration for the rehabilitation of apatient with implants is the prevention of papillaloss because surgical reconstruction of this arearemains unpredictable.9,10If there is bone loss at the facial aspect of theimplant and the patient presents a thin biotype,the soft tissue margin can migrate apically andgenerate esthetic or functional complaints.11 Soft tissuerecessions in implants leads to a longer prostheticcrown with incorrect tooth proportion or abutment,and the implant may also be exposed, which makesplaque control even harder, especially if there is lackof keratinized mucosa.12,13 Therefore, patients mayrequest some type of treatment to prevent furthertissue loss or to regain previously lost tissue.Treatment of soft tissue defects around implants ischallenging, especially in the esthetic region (Figure 1).To quantify soft tissue esthetic parameters, the PinkEsthetic Score14 was developed to evaluate mesialand distal papilla, soft tissue margin and contourFigure 1. Clinical alterations in an implant placed in theanterior region.2Braz. Oral Res. 2019;33(suppl):e073and alveolar process volume, color and texture. Eachvariable receives a grade from 0 to 2, and the patientsoft tissue esthetic receives an overall value from 0 to14. Belser et al.15 modified the original score, and therevised evaluation varies from 0 to 10. The variablesof the alveolar process (volume, color and texture)were condensed into one analysis, which the authorsjustified because these variables were not consideredas equally important as the other variables.Similarly, the correction of peri-implant recessionor papilla loss is more technically demanding thanincreasing the soft tissue volume or treating colorand texture alterations. This narrative reviewdiscusses these types of soft tissue defects aroundimplants and the possible treatments proposed inthe scientific literature.Facial volume loss, color or texturealterationsLoss of facial volume generally occurs after toothextraction, especially if there is a bone defect in thesocket. A great percentage of resorption occurs inthe first 3 months, but resorption may continue upto years after extraction in sockets that originallycontained a facial bone wall.16 If the implant is placedwith no further soft or hard tissue regeneration, thenthe mucosa may become thin and present a grayishcolor in the facial aspect.17 Additionally, the soft tissuetexture may present scars depending on where theincisions are placed and how the flap is managed;soft and hard tissue grafts may also alter the tissuetexture if exposed.18A ridge concavity in the area that received animplant may become a concern for patients whopresent high esthetic demands. Volume loss is partof a physiological phenomenon that occurs aftertooth extraction. Several researchers demonstratedthat the facial wall was partly resorbed due to itsthickness, in contrast to a thicker lingual or palatalwall that generally exhibits less resorption.5,6,16 Bonegrafts reduce the volume loss, and deproteinizedbovine bone mineral (DBBM), which are small-sizedparticles of autogenous bone and synthetic materials,such as beta tricalcium phosphate, exhibit morestability but show limited results as materials toprevent ridge resorption.5,6,16,19 A human autopsy
Frizzera F, Oliveira GJPL, Shibli JÁ, Moraes KC, Marcantonio EB, Marcantoni Junior Estudy of one patient who received implants inhealed ridges and presented a facial dehiscencethat was grafted with distinct bone grafts showedvery different clinical and histological results. Oneside was grafted with deproteinized bovine bonemineral and a collagen membrane, and the otherside received autogenous bone chips in contactwith the implant followed by a biphasic calciumphosphate graft and a collagen membrane. Theimplant grafted with the autogenous and syntheticbone grafts exhibited recurrence of bone dehiscenceand mucosal recession at the facial aspect.20The loss of facial volume may be associated witha thin or nonexisting facial bone wall. Consequently,the soft tissue also becomes thin in such areas, whichmay predispose the patient to develop mucosalrecession or color alterations. Tissue thickness isclassified as thin when it is less than 2 mm at thefacial aspect, and as thick if presents a value greaterthan 2 mm. Depending on the thickness of themucosa, the facial color may be altered by showingthe implant or abutment due to transparency.21 Anin vitro study compared the color alterations ofmetal or zirconia abutment in different mucosathickness. No color alterations were perceivedwhen the mucosa exhibited a thickness of 3 mm.Titanium abutments showed a grayish area at thefacial aspect in the presence of a 2 mm thick mucosa,while zirconia abutments did not and provided abetter color aspect. If the tissue exhibited a thicknessof 1.5 mm, all abutments showed discoloration ofthe mucosa.22 To treat color alterations that occurdue to reduced tissue thickness and transparencyof the mucosa, a soft tissue graft may be indicatedto augment the facial volume and provide stableresults in the long term.23 Different types of softtissue grafts are used for different purposes aroundteeth or implants. To increase soft tissue volume,autogenous connective tissue grafts (CTG) providedbetter results than homogenous acellular dermalmatrices or heterogenous collagen matrices.9,11,23Depending of the extent of volume loss, the defectmay be treated with a CTG and different types offlaps. If the implant is submerged and the defect atthe cervical area is smaller than 2 mm, a lingualincision to facially position the flap solves the volumeissue. If the defect is greater than 2 mm, a CTG mustbe associated with this type of flap. In situationswhere the implant is already exposed and exhibitsa healing abutment, provisional or ceramic crown,the defect may be treated with a CTG and pouch flapif the defect is smaller than 2 mm. For larger defects( 2 mm), an envelope flap may be performed andassociated with a CTG to provide better volume at thefacial aspect. A systematic review demonstrated thatthe use of autogenous soft tissue grafts to increasemucosal thickness resulted in less marginal boneloss over time.7Care must be taken whenever performing incisionsin esthetic regions to avoid the formation of scars.Wessels et al.18 proposed a scar index that evaluatesthe scar width, height/contour and color and classifiesthe visibility of the suture marks and the overallappearance. A randomized clinical trial compared thesoft tissue response after intrasulcular and trapezoidalincisions. Scars were present in the trapezoidal groupand clearly visible in greater than 85% of the mesialand distal vertical incisions 1 month after surgery.After 12 months, the scars were less pronouncedbut could still be identified in more than half of theperformed trapezoidal incisions.24To improve the soft tissue texture and reducescars in the facial aspect of an implant, a mucosalpeeling may be performed by using a surgical blade,conventional or ceramic burs or a high frequencylaser.25 It is important to evaluate tissue thicknessprior to peeling. If the tissue is thin, then its removalmay lead to soft tissue alterations, such as recessionor loss of papilla, and a CTG may be indicated toincrease tissue thickness prior to scar removal inthis situation.Peri-implant recessionIn the past, peri-implant recession (PIR) was acommon condition in implant dentistry becausethe implants were installed in the existing bone,and the primary endpoint of the therapy was toprovide masticatory function. With the evolution ofimplant systems, prosthetic and surgical techniques,it became possible to restore a single missing tooth,but most implants exhibited longer clinical crowns.26The current understanding of the importance ofBraz. Oral Res. 2019;33(suppl):e0733
Treatment of peri-implant soft tissue defects: a narrative reviewtissue regeneration and implant selection andpositioning to provide better esthetic outcomesallows clinicians to restore implants even in highlydemanding situations.9Multiple factors influence in the occurrence of PIR,including implants that were placed facially or apically,areas that exhibit bone dehiscence, thin periodontalbiotype, an improper quantity of keratinized tissueand areas submitted to trauma.27,28 Similar to gingivalrecession, peri-implant margin apical migration tendsto increase over time, and regular maintenance isimportant to identify the factors causing the tissue loss.In esthetically demanding situations or progressiverecession, treatment must be performed to stabilizeor recover the lost mucosa.12,13The presence of keratinized mucosa is widelydiscussed to define its role in the prevention ofinflammation, PIR and diseases. Some long-termretrospective studies demonstrated that reducedkeratinized mucosa width and shallow vestibuleswere associated with more recession and bone loss,29and performing an apically positioned flap andautogenous free gingival graft led to better clinicaloutcomes and prevented peri-implant recessionand inflammation.30 Oral hygiene becomes easierto perform, especially in posterior regions afterincreasing the width of keratinized mucosa and thevestibule, which also prevents or limits the occurrenceof peri-implant diseases.27,29Implants that exhibited a large diameter orplatform used to be placed in sockets or ridges torestore anterior teeth.31,32,33 Peri-implant recessionsoccurred in these situations, especially in patientswho exhibited a thin biotype or facial wall, and whodid not receive guided bone regeneration or softtissue grafting to increase tissue thickness. Kan etal.34 performed immediate implant placement andprovisionalization in maxillary anterior socketswithout performing any type of grafting. A meanperi-implant recession of 0.55 ( 0.53) mm wasreported, but most of the implants (74.28%) wereplaced in maxillary central incisor sockets, whichare more predisposed to ridge dimensional changesthan maxillary lateral incisors. The patients from thisstudy were reevaluated after a mean follow up of 4years (range 2 to 8.2 years), and a significant difference4Braz. Oral Res. 2019;33(suppl):e073in the extent of peri-implant recession in biotypesclassified as thin (recession 1.50 0.88) comparedto thick (recession 0.56 0.46) was reported.35Bone morphology was associated with periimplant thickness and recession in a clinical study.36Thicker facial bone walls were correlated to thickbiotypes, and bone walls that were thin or exhibited adehiscence defect were associated with longer clinicalcrowns or recession, respectively.36 A minimum bonethickness of 1 mm must be achieved in the facialaspect of the implant to provide more stability andnutrition to the mucosa. Several studies have shownthat the selection of the implant proper diameter andplacement in a lingual position creates or maintainsproper thickness of the facial tissue when bone andsoft tissue grafting are performed.9,31,35Treatments of PIR around implants are morecomplex than teeth. The peri-implant tissue hasa lower blood supply, and its fibers differs fromthe gingiva.37 To increase treatment predictability,other characteristics must be evaluated prior to softtissue grafting of implants with PIR. Implant size,quantity and position, prosthetic abutment andcontour, the extent of the bone defects at the facialand interproximal levels are important aspects thatplay major roles in implant coverage.33 Depending onthe clinical situation, implant removal, followed byridge reconstruction and placement of a new implantin the proper tridimensional position, provide a morepredictable outcome and better prognosis than softtissue grafting for implant coverage (Table).The implant position and prosthetic contour(abutment and provisional/crown) is important toachieve predictable results. The implant inclinationand crown emergence must not cross a line thatconnects the adjacent tooth at the cervical region,meaning that the implant/prosthesis should notoccupy the space where the mucosa should be. Inthese situations, the abutment must be horizontallyreduced and exhibit a concave contour to providemore space for the soft tissues; some authors haveeven proposed facial implantoplasty to increase PIRcoverage.38 The vertical position of the finishing lineof the abutment must be moved coronally to near or atthe level of the soft tissue margin of the contralateraltooth/implant.
Frizzera F, Oliveira GJPL, Shibli JÁ, Moraes KC, Marcantonio EB, Marcantoni Junior ETable. Factors that influence prognosis of implant coverage with soft tissue grafts.Factor / PrognosisGoodModerateBadImplant 3D positionProperFairMalpositionedProsthetic/abutment contourConcaveFlatConvexImplant diameterNarrowRegularLargeTissue thicknessThickThinThin with fenestrationPeri-implant recessionShallowModerateDeepDistance implant platform to bone crest 3 mm 3 mm and 6 mm 6 mmInterproximal tissue lossNoneSmall defectLarge defectImplant adjacent toTeethTooth and implantImplantsPosition of the implant within bony envelopeInsideAt bony envelope limitOutsideABCDEFFigure 2. An implant that had a thin biotype and peri-implant recession (a) was treated by using a combination of prosthetic andsurgical procedures. The implant crown and metal abutment (b) were removed, and an impression of the implant was performed tocreate a new zirconia abutment with a concave contour, in which the finishing line was placed at the level of the soft tissue marginof the contralateral tooth (c). Two vertical incisions were performed to create a full/split thickness flap (d). A thick connective tissuewas sutured at the level of the abutment finishing line (e), and the flap was positioned coronally (f).An implant with an adequate diameter that isplaced in a favorable tridimensional position within thebony envelope with limited or without interproximaltissue loss is a good candidate to receive soft tissuegrafting for the treatment of PIR. Although thereare few prospective studies that address this typeof defect, partial to full coverage may be expecteddepending on the extent of the clinical alteration andoverall prognosis.2,12,38,39 Shibli et al.40 proposed oneof the first published methods to treat PIR in 2004and reported that recession was successfully treatedby using a combination of prosthetic and surgicalprocedures. The abutment diameter and provisionalwere initially reduced in its facial aspect followed bya coronally advanced flap (CAF) that was associatedwith a thick CTG graft (Figure 2).Because there are many variables in the diagnosis,indication for treatment and prognosis, few clinicalstudies report data on coverage of peri-implantrecessions. Burkhardt et al.12 evaluated 10 patientswho underwent soft tissue augmentation to treat asingle PIR with a mean value of 3 mm (SD 0.8 mm).The connective tissue graft removed from the palateexhibited a thickness of 1.5-2 mm, and a flap withtwo vertical incisions was coronally advanced 2 mmfurther to a landmark measured in the contralateraltooth; there was no report of implant abutmentor prosthesis modification. Six months after theprocedure, there was a mean coverage of 66% (SD18%) of the peri-implant recessions, and a positivecorrelation between flap thickness and recessioncoverage was reported.A prospective study was performed to treatPIR and presented clinical results after one38 andfive years of follow-up.13 After patient selection,the prosthesis abutment was reduced at the facialBraz. Oral Res. 2019;33(suppl):e0735
Treatment of peri-implant soft tissue
Treatment of peri-implant soft tissue defects a narrative review Some papilla loss around dental implants is expected regardless of the type of implant placement, especially when several surgical procedures are performed to rehabilitate a patient. 8 This loss may be reduced by performing a flapless immediate implant
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increase an implant recipient's risk of peri-implantitis and implant failure. The present review aimed to synthesize evidence from studies examining the role of mental health conditions and SSRI use in peri-implantitis and dental implant failure risk. Key Findings Antidepressant use at the time of implant placement likely
9. Straumann PURE Ceramic Implant Monotype 35. 9.1 Design 37. 10. Surgical procedure for Straumann PURE Ceramic Implant Monotype 38. 10.1 Preoperative planning 38 10.2 Basic implant bed preparation 42 10.3 Fine implant bed preparation 45 10.4 Implant insertion 46. 11. Prosthetic procedure for Straumann PURE Ceramic Implant Monotype 49
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Force Factors Related to Patient Conditions11. Implant Site Bone Density: A Key Determinant for Treatment Planning12. Key Implant Positions and Number for Fixed Implant Prosthesis: A Biomechanical Rationale13. Dental Implant Body Size: A Biomechanical and Esthetic Rationale14. Available Bone and Dental Implant Treatment Plans15.
Clinical Case: Mucogingival implant therapy: correcting the mucosal sequelae of peri-implantitis Figure 2 5. Intraoral exploration: Marginal gingivitis at prosthetic implant abutments and peri-implant mucositi
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