Concepts of peri-implant tissue planning
Plan :
Introduction
1-application of periodontal plastic surgery techniques to implants
2-peri-implant tissue arrangement before implant placement
3-peri-implant tissue arrangement during implant placement
4-peri-implant tissue development during or after the second implant stage
5-peri-implant tissue development after implant placement
Conclusion
Bibliography
Introduction: Peri-implant plastic surgery is an extension of periodontal plastic surgery since it deals with the prevention and correction of anatomical, traumatic or pathological defects of the peri-implant mucosa.
The goal of implant dentistry is to create a tissue environment comparable to that of a tooth.
1-Application of periodontal plastic surgery techniques to implants
1-Place of periodontal plastic surgery : the development of peri-implant soft tissues can occur at several stages of treatment:
- during the pre-implant phase
- at the time of implant placement
- after osteointegration during the prosthetic phase.
Concepts of peri-implant tissue planning
Plastic surgery may be necessary more rarely after fitting the prosthesis (if the stability of the soft tissues is not ensured).
2-Factors influencing decision-making : the choice of treatment time and surgical technique depends on the analysis of the clinical situation. Certain factors are likely to influence this choice:
-Aesthetic components : we will note:
-the patient’s request
-the smile line
– alignment of the collars
-the shape of the taste buds
-the need to modify anatomical or morphological anomalies.
Tissue component : Soft tissues are supported by underlying hard tissues and the durability of the peri-implant tissue complex is closely linked to the bone tissue.
The need to treat a bone defect around the implants influences the choice of the type of mucosal development and its timing in the treatment timeline. It should be noted:
-the quality (keratinized tissue) and quantity of soft tissue (height, thickness)
-available bone volume
Prosthetic component : decision-making must include the following data:
-the position and number of implants
-the choice of the type of implant and connection
– timing solutions
3-Choice of technique : among the periodontal plastic surgery techniques adapted to implants, we distinguish between techniques without tissue input and techniques with tissue input.
-Techniques without tissue input consist of using the tissue environment already present by displacement flaps to optimize peri-implant tissue quality.
– techniques with tissue input consist of correcting an adjacent tissue environment that is insufficient either in quantity or quality. A distinction is made between epithelial-connective tissue grafting and buried connective tissue grafting techniques.
The choice of technique depends on the need to modify either the quality (supply of keratinized tissue) or the quantity (insufficient volume) of the soft tissues and the anatomical area of the implant site.
2-Arrangement of peri-implant soft tissues before implant placement
Directions:
– significant deficit of keratinized tissue. This situation is most often found in the posterior mandibular sectors that have been edentulous for some time in patients with a thin tissue phenotype.
-old edentulism associated or not with the wearing of a partial removable prosthesis accompanied by a reduction in the crestal quantity of keratinized tissue
Surgical techniques :
– epithelial-conjunctival graft: the association of an epithelial-conjunctival graft with the apically displaced flap allows a significant increase in the height and thickness of keratinized tissue.
3-Arrangement of peri-implant soft tissues during implant placement
Indications: Tissue development can be performed at the same time as surgical placement of implants using non-additive or additive techniques.
– Non-input techniques are indicated when the soft tissues on the edentulous crest or in its immediate environment are sufficient in both quantity and quality. In these conditions, soft tissue management aims to preserve the pre-existing anatomy or to optimize tissue distribution by displaced flaps.
-techniques with contribution are indicated to correct a tissue deficit by the use of connective or epithelial-connective graft.
Surgical techniques :
Technique without contribution :
Flapless surgery: it has been proposed to reduce postoperative sequelae. It is considered in ideal tissue conditions both in terms of bone volume and gingival phenotype. It consists of the elimination of a gingival cap with the dimensions of the implant on the edentulous ridge in order to allow the passage of implant drills. These techniques are limited to trained operators in easy anatomical conditions (surgical accessibility, width of the ridges, available bone height)
Displaced flap: Soft tissue displacement is most commonly performed when placing healing abutments on implants.
To preserve a sufficient amount of keratinized tissue, it is recommended to make offset crestal incisions in the palatal direction in order to move the crestal keratinized tissue apically and vestibularly. The flap is first made in full thickness (to allow the implant to be placed) then in partial thickness to allow it to be mobilized and moved apically.
After placement of the healing pillar, the apicalized flap is sutured at the periosteum and around the pillar.
Pedicled flap: among the pedicled flap techniques, rotation flaps are distinguished.
Tissue-delivered techniques : Surgical techniques with tissue delivery during implant placement are often indicated in the area where the immediate environment does not allow for soft tissue displacement.
A lack of keratinized tissue requires an epithelial-connective tissue graft.
Concepts of peri-implant tissue planning
4-Arrangement of peri-implant soft tissues during or after the second implant stage
Directions:
– burial of implants is sometimes necessary for reasons of bone reconstruction, implant stability or temporization. Soft tissue management is then preferable during the second implant stage.
Surgical techniques:
Technique without tissue input:
Surgical techniques without tissue input are identical to those performed during implant placement. If an increase in tissue volume is necessary vestibular to the implant, either simple displaced flap techniques or those with pedicled connective tissue are indicated.
Technique with tissue contribution : during the second implant stage, tissue development can be done using techniques with tissue contribution such as epithelial-connective grafting or buried connective tissue grafting.
5-Arrangement of peri-implant soft tissues after placement of the prosthesis
Indications: The indications for peri-implant plastic surgery after implants have been put into operation are:
-the assessment of the volume and quality of soft tissues was poorly estimated during the surgical phases preceding loading and their modification was not integrated into the treatment plan.
-appearance of tissue changes due to poor implant positioning.
-appearance of tissue changes generating inflammatory problems.
Surgical techniques : Soft tissue management is difficult once implant treatment is completed. Techniques with tissue input such as epithelial-connective grafts and buried connectives or the use of collagen membrane are possible.
Conclusion: Many peri-implant tissue management protocols are available during the different phases of treatment. However, the choice of surgical technique often remains a decision subject to the skill and experience of the surgeon.
Bibliography:
-Philippe Bouchard periodontology implant dentistry volume 2 therapeutic surgical Lvoisier Medicine
-Naoshi Sato Yuzawa Japan Clinical Atlas of Periodontal Surgery Quintessence International
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