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Running Time: 50 min

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In this lecture, discover how to utilize Soft Tissue Grafting for correcting implant complications. Utilize 5 pink dilemmas to analyze the implant complications in the esthetic zone. Determine what the problem is: Is it a buccal concavity problem? Marginal recession? Papilla loss? Asymmetry? Or is it a color & texture problem? Utilize several soft tissue techniques: free gingival graft; connective tissue graft; modified roll technique; and modified VIP-CT technique. For the purposes of correction Dr. Lin breaks down implant complications into 7 categories. The steps for managing implant complications are similar to periodontal therapy. With proper case selection, patient selection, and procedure selection you will be able to achieve management of complications by soft tissue in a predictable way.

Release Date: October 02, 2012

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Hi, this is Paul Lin from Taiwan again. Today, I’ll be sharing with you the topics Soft Tissue Grafting for Implant Complications in the Esthetic zone. The inspiration from treating periodontal deficiencies. I’ll be dividing today’s topic into four divisions. Chapter one is the introduction. Chapter two is soft tissue procedures that I’ve likely utilized. Chapter three is the management of implant complications. I’ll be showing some case reports. The last is chapter four, I’ll make some couple concluding remarks. So first is introduction. Let me show you some cases that require soft issue grafting. But before then, according to ITI Consensus 2007, the presence of soft tissue defect for esthetic risk assessment for dentures site is considered high risk. What about the parallel defect with a recession like this? We can correct it easily by soft tissue grafting. We call it a [INAUDIBLE]. A defect in conjunction with boning defect, not just soft tissue defect, can be corrected with Emdogain, bone graft, and connective tissue graft to correct the defect. It’s called periodontal regeneration and root coverage. In a case like this, where the teeth is failing, and we decide to have it removed, followed by immediate indent placement, and cover with bone graft membrane, and soft tissue occlusal seal. And we perform the second stage. And it was the final. We call it immediate implant placement with hard and soft tissue grafting. What about this? After functioning for 15 years of a blade implant, there appear to be an infection together with root recession. Can we correct the defect predictably? We can try, but how come how will this last? Management of implant complication with root coverages may be obtained, but is there any way we can do it more predictably? In this procedure, root coverage we call it, predictable and achievable root coverage together with regeneration. [INAUDIBLE] placement with 3D bone grafting and soft tissue grafting, it’s possible. And this, I call it, daring. If we put the risk assessment– while I think both the first predictable and achievable is considered over 80% of the time that is consistent. And anywhere from daring is less than 50% or possible. But with careful selection of the case and utilizing a proper technique, I think in these cases, with implant complication, you can achieve with certain degree of predictable result. A popular lost. A real coverage. A ridge augmentation and root coverages at the same time. Or this question and recession, can we correct it? Root coverages and ridge augmentation in conjunction with perientitus. First, we’ll have to understand the difference between natural root and dental implant in four aspects. First, the biological aspect. Second is the function aspect. Third is the esthetic aspect. Fourth is the management of complication is somewhat differently. Biologically, first, we have to look at the similar dimension. We call it biological width, which was described by Gargulo in 1961. The result that was found by Berglund and Lindhe, the junction epitheleum consists of two millimeter, and connective tissue a little over one millimeter. This is the similar result that was found by Cochran. But there’s much difference in the blood supply. And also, the reverse ratio of the width and height. The biologic difference in fiber support is mainly different from the anchoring fiber groups from natural root to gingival. But nothing there from implant to peri-implant mucosal seal. So what was found by Berglund and Lindhe is a peri-implant soft tissue seal appears to be weaker than the natural teeth. Most of the time, when you probe, if the crown is removed, you can get a sounding situation here. So in summary, by [INAUDIBLE], the perspective differences between natural teeth and implanted biology is lack of connective tissue attachment, hypovascular and hypocellular CT zone and implant, and absence of periodontal ligament blood supply. And what do we utilize this concept in clinical situation? The implication is poor blood supply, weak fiber attachment, slow in responding to stimulus, and quick in yielding to disease. So the application of the clinical procedure has to be, if possible, to deal with that perspective to hopefully perform pediculated graft as much as possible, and minimize verticals and preserve papilla, and to provide a regular checkup for implant patient, and to perform early intervention once there is a symptom or signs. The functional of differences of dental implant could be the necessity of the keratinised mucosa next to the restored implant prosthesis. The clinical significance of keratinised mucosa could be prevents the spread of inflammation to deep tissue, may prevent recession of marginal gingiva, and prevent excessive movement of the free gingiva, to resist the damage from brushing, and to prevent esthetic compromization according to Ono and Nevins. What about esthetics? I will next utilize the concept of five fundamental elements described by Sascha Jovanovich. It’s first to satisfy the bone foundation, and then to provide a good selection of implant design and plays in 3D correct position. Third is to provide a good soft tissue profile for us. And then to perform prosthetic tissue support. And fifth is to then fabricate good ceramic art design. About soft tissue profile. It’s not one factor that stands alone. It has to rely on the evidence of good bone foundation and implant design and position. So esthetic implant dentistry, described by Palacci, the key concept, the replacement of missing anterior teeth, you have to think in terms of the creation of a normal alveolar contour, not just to restore the alveolar process, as well as the current soft tissue. So firstly, the bone foundation, and then implant placement in 3D position, and the soft tissue profile. Then the transgigival support by the abutment, and then the choice of good artificial art design. So what are complications? The management of implant complication, described Stuart Froum could be in five categories. First is implant/screw fracture loosening. Second is implant failure. Third is infection. We call it peri-implantitis, or peri-mucositis, forces poor implant positioning. Fifth is poor esthetic result. Now, if you were to treat implant complication with an implant inside you, if you want to keep the implant, then there’s three things we had to deal with, if possible, to correct the infection. And to hopefully cover up the poor implant positioning and poor esthetic result and to provide esthetic present result in anterior region. According to Spiekermann in 1991, after implant was placed, the implant was subjected to oral environment for aging, disease, and sometimes even implant lost could be occurred. This incidence could be on any natural teeth as well. However, the predictability of management of the situation in implant is much lower in terms of correcting the situation, in particular in esthetic zone. We call it birth, aging, diseased, and failing. According to Stuart Froum, he described that for poor implant positioning and poor aesthetic result, the predictable result is only on single implant, not on multiple implants. So the second chapter, we’ll look at the soft tissue procedure, likely that I will utilize and recommend. There’s two major categories. One is called the soft tissue graft. The second pediculated flap. The soft tissue graft consists of free gingival graft and connective tissue graft. Well, free autogenous gingival graft is also called free gingival graft, described by neighbors. That was long before what was described as subepithelial graft by Langer. You can appreciate that the differences of the esthetic result of the connective tissue graft. So in the esthetic zone, likely, the majority of the graft procedure will be utilizing connective tissue graft. However, there are some situations where the free gingival graft can come into play. For example, the free gingival onlay graft, in this situation, we can correct on top of the resorbed implant surface. The onlay graft can provide a good [INAUDIBLE] of the tissue. And it to perform the apical position flap, prior to the free gingival graft procedure, it’s very important to first make sure you have at least one millimeter of connective tissue that is applicably positioned. By making partial thickness incision, you can lower down an applicable position, the flap. And secure the flap. Sometimes the suture could be going this way, but often time, if you were to do it vertically, there’s a good chance you can pull up the tissue up a little bit, and the receiving band will become a little smaller. The best procedure to secure the flap applicability is to perform a horizontal mattress suture while penetrating the Shapiro flap and underneath periosteum into four points. And anchor it a little bit applicably to the covering flap. With these four points, you can make one suture, and you can lower down the flap even a little more. Now, with this case, is after certain grafting procedures to correct this implant loss. The soft tissue defect was grafted primarily with connected flab. But superficially, it was later grafted with free gingival graft to provide good vertical height, as well as the look of the papilla. Secondly, let’s look at the connective tissue graft. It was described by Langer to correct the class one to three moderate defect. It’s mostly often used. It can be used in conjunction with hard tissue grafting. And this is an incision for the recipient side that I would recommend. And instead of going from the sulcus it’s for implant complication, in particular for thinner periodontium, I would approach from a side pouch. And while making the elevation, it’s important to leave some pareosteum intact. And while harvesting, the covering flap should be thin as much as you can to harvest the thicker tissue if for thin periodontium. Hopefully, we can obtain a thickness of more than 1.5 millimeter of thickness. So the connective tissue graft can be harvested from multiple sites. I would say, firstly, from retro molar or area. Or secondly, from internal flap. And thirdly, from pallet area. From retromolar area, the graft, after harvested, it’s important that you have it epithelialized. You don’t have to remove all the epithelial line, just peel off the very superficial layer, less than 0.5 millimeter. And you can cut into half and expand the graft a little bit for future use. Or the donor tissue from palate, after harvested, you have to remove the adipose tissue and shape the tissue in more of a pleasant form for future use. About the soft tissue technique that describes– we call it pediculated flap. There’s two ways we can do it. One is called modified rolled technique. The second is called modified VIP-CT. For modified roll technique, firstly, we have to understand, previously it was described by Abrams, 1980. It was mainly to utilize, to correct class one, mild to moderate defect, to increase the buccal thickness slightly. But it all depends on the thickness of the palatal tissue. You have to have to have a thick palatal tissue, hopefully more than three millimeters, in order to get good roll tissue to move it buccally. However, the original Abrams roll technique, the palatal tissue was epithelialized, and it caused much pain for the patient. And Dr. Tarnow modified it with epithelialized retention. My modification is not only epithelial retention, as well as periosteal retention on the recipient side. To increase the buccal thickness for endentulous area, in this case, tooth number 10. You can do that if only minor defect. And for implant during the second stage, you can increase at least one to two millimeter of thickness to make it more pleasant. This is the procedure that I’ve described in the previous series of videos. The graft tissue, harvested from the palate, should be thick enough, hopefully more than 1.5 millimeter to help correcting the buccal deformity before the second stage, before the final restoration will be made. However, there’s some time you have to correct the buccal deformity, slightly concaved. In this case, it’s after you remove the abutment, you can elevate the flap and the graft on the palate, and increase the buccal thickness in this case. And what’s best about this roll technique, you can even correct the buccal deficiency with some implant complication that shows through during this the second stage. Let’s look at the modified VIP-CT by pediculated flap. Now, originally described by Antonin Sclar as demand for a class three moderate to severe defect. It maintains a good vascular blood supply, and can be used with hard tissue grafting in conjunction. However, it was described that the periosteal to be retained on the flap side that was mobilized to cover to the recipient side. I would like to utilize it a little differently. I call it a modified VIP-CT with a periosteal retention on the recipient side is not mobilized at all. So by performing that, this is a little modification of the roll technique, with a little longer lag on one side extending posterially in order to harvest the wider and thicker graft from the posterior region. And you elevate the partial thickness with periosteal retention, and then cover it to the recipient side, to provide a occlusal seal as well as a good papila regeneration. So let’s look at the management implant complication in several cases. The optimal smile can be enhanced with periodontal esthetic procedure that was described in my previous DVD. I utilized primarily five categories to look at that. First, we have to know the treatment procedures to control inflammation. Second, we look at how to improve the gingival contour to look at the margin, to look at the papila. And third, if the involvement of papila will be done, then we have a thing in terms of how not to affect the papila in the future height, to preserve a papila, or even if possible, to augment the papila. Fourthly, if there is a defect where we have to remove the tooth or the implant. We have a thing in terms of a socket preservation. The fifth is if there’s concavity on the buccal surface, or on the ridge vertically, horizontally, we can think in terms of how we can perform ridge augmentation to optimize the esthetic result on the implant. From gingival characteristics, there is certain procedures mainly to focus on increasing the size. After increasing the size of the gingiva, there’s good chance that you may be able to improve the contour, and then to correct the color , and then maybe improve the consistency and surface texture. Size and contour will be the first two criteria to look at. Now, with that satisfied, we can easily get the gingival margin in a good scalloping, good papila height. And thirdly, what we’re looking at are the color changes. If possible, we could provide more of a pink look of the tissue. So described by Stephan Chan or [? Belsier ?], there is various pink esthetic score that have been utilized. This is by Stephan Chan. He utilized seven pink esthetic scores to evaluate the optimal result after implant placement. He utilized– evaluate the medial papila, the distal papila, the level of soft tissue margin and the soft tissue contour, alveolar process, color and texture. In these seven categories. For me, to correct implant complications, it is easy to utilize in my cases five pink dilemmas. First, to look at it, there’s an existence of buccal cavity. It’s probably much easier to correct that way. And second, to see if there’s a marginal recession. Third, to see if there’s a papilla loss. Fourth, to make sure that this particular tooth in the smile zone, is it symmetrically achievable? And fifth is whether or not we can change the color and texture. So treating the implant complication can be divided into seven categories, in addition to poor esthetics, there’s implant infection, where there’s a presence of mucositis or peri-implantitis. Or where there’s a presence of tooth implant poor positioning. I categorized into three different levels of difficulties. Level one is minor or no difficulties. Lever two is moderate difficulties. Level three is major difficulties. And I would score them accordingly. One point, two points, and three points. So each case, during my management, I would give a previous score and to give me an idea of how hard it is to perform the treatment. So in controlled inflammation, I have to go back to the traditional treatment of periodontal therapy. To make sure that all other teeth are disease controlled periodontally. And then I’ll treat– if there’s a problem of the teeth adjacent to implant to see if there’s poor esthetics or poor function. And I’ll treat a disease, whether or not we have to remove the teeth or to keep it, depends on certain criteria. The key is not the main issue that I will discuss today. But this is how I would treat the regular or traditional perio patient. The management of implant complication appears to be sharing the similar treatment sequence in the decision tree. First, you have to determine there’s evidence of pericementitis by probing, bleeding, pocket death, pus formation, bone loss. And then you have to treat the teeth according to whether or not you want to keep the fixture. If there’s evidence of mobility or any bone remaining less than one third of the bone, or the implant is failing regardless of treatment, and then you consider to have it removed. Otherwise, there’s always a chance we can try to rescue the implant. Now, in most of the case, the rescue was done under the permission of the patient, or the request of the patient. But to provide a treatment, there is– non-surgical treatment should be provided first by hand scaling and then utilize cool hexadine, and slow releasing minocycline gel. And I would utilize ultrasonic as a secondary to henchmen. And in some cases, nonsurgical, I would utilize laser. But hardly. Mainly we utilize during the surgery. Now, for surgical procedure, we have to determine whether there’s evidence of horizontal defect or vertical defect. I would, mostly for esthetic purpose, to provide a treatment, either to submerge it if there is evidence of bone loss and papila loss. I would submerge the case. And I would regenerate what was missing by GBR or maybe by bone grafting. And I would certainly provide a soft tissue graft in conjunction with the previous procedures. Take this, for example. The control of inflammation for natural dentition in the esthetic zone, I likely would utilize not the regular q red, but rather a q red that has a very small tip. It was described as what we call a curvette, with smaller tip and dimension. And with longer terminal shank that will allow you to go deeper enough, and at the same time, cleaning the root. For implant debridement non-surgically, I would utilize titanium tipped scalar and q red. And this is the slow releasing agent that I used by Sun Star mostly. And the laser I will be utilizing is called Erbium laser. Take this case, for example. There’s evidence of possible inflammation after several episodes of scaling or root planning. Still, we cannot control the inflammation. And we decided to have a regeneration. In this case, patient choose not to have a submerged implant done. So we then opened it up, and then degranulate it, and then decontaminate the root to a certain degree by rotary drill, a finishing drill. And then tetracycline disinfection. And then laser disinfection to achieve, hopefully, a non-contaminated implant service. And they we will place a bone graft. Prior to that, secure the membrane, and the membrane placement. So this is the case that we can achieve the bone regeneration around dental implant utilizing guided bone regeneration technique. Let’s look at case number one. It’s a 33 year old male, who works in the bank as a security officer. And he described that number six, or number 13, has a darker color and become longer over the few weeks. This was a provisional after implant was exposed. And the continuous tissue loss was found. And the patient asked the restored dentist to make a longer restoration, and which is not pleasant, so the patient was referred here for correcting the problems. The problem we found here is a buccal concavity. And the marginal recession and the color, because of the show through of the implant. Appeared to have a dark color. In this case, we would like to have a treatment plan, non-submerged implant. And we will provide one piece of connective tissue graft for correcting all the problems. How can we do that? Let’s look at the analysis chart. This patient has moderate buccal concavity, moderate marginal recession, and one tooth that is asymmetrical. And there’s problem with the color. The total score is six. So the procedure that would be utilized to improve the general contour, and also to augment the ridge. For this, we have to rescue the implant. We provide a treatment for esthetic purpose, mainly through soft tissue grafting. There’s no evidence perio-implantitis in this case, so we don’t have to submerge or provide hard tissue grafting procedures. What I did on this case to make a little pouch that was about three millimeters from the gingival margin of the implant, and I would insert the graft inside by elevating partial thickness flap without making any incision to the crestal of the implant. And I will harvest from palate. After harvest, we can stuff the graft tissue inside. And this cured with resorbable suture. You can appreciate that the buccanus that was obtained after the graft was secured into place. Now, without removal of the abutment, you can tell that there’s still marginal area. Somewhat submarginal finishing line. So in two weeks, prior to suture removal, you can see there’s a migration of the marginal tissue to cover the margins subgingivally now, close to 0.5 to one millimeter. In two months, there’s even more migration of gingival margin to now one to two millimeters. The buccal thickness remains, however, the margin tissue migrated down to a substantial degree after two years. Four years, it appears that the tissue stabilized over time, and the patient can maintain good perioimplant health. So this is the current status. That was before. This is during the surgery. And just a few months after the surgery, noticing the changes of the gingival margin over time. See that the importance of the thickness of the buccal tissue would change over time. And that can be utilized for the cases like this, where there’s a medium placement performed on the fenestration type of buccal bony defect. And the future tissue loss, in conjunction with not just buccal concavity, as well as marginal recession, we can correct the same concept using pouch approach and one piece of connective tissue graft to pump up the buccal thickness, as well as lower down in the gingival margin. So the concept for the biological differences is the width for height. So we increase the width of the buccal thickness of the implant, we can somehow increase the height of the buccal tissue. Let’s look at number two. Case number two is a 28-year-old female. She’s a dental assistant. She complained tooth number seven, or number one, two is too long. And we notice that there’s a problem with marginal recession, with poor implant positioning, as well as asymmetry, compared to the contralateral teeth. The treatment that will be involved to submerge this tooth. There’s no buccal concavity occurred. In order to bring the margin of the buccal tissue down, as well as lingual. As you can see from here, we probably have to utilize the VIP-CT. In this case, I utilized a modified VIP-CT. But once that was harvested, if there’s additional tissue may be necessary, I would also incorporate a connective tissue graft. So the majority of the procedure was involving improvement of the gingival contour in this case. So in complication analysis, I would score this case as a nine, having the buccally averted implant position, and somewhat apical position. And with evidence of marginal recession, severe marginal recession, and asymmetry to the gingival alignment. For management of the complication, we have to think in terms of poor esthetic and poor implant positioning. And for esthetic result, I like to submerge this case and perform a soft tissue grafting. And I would utilize modified VIP-CT in conjunction with the graft harvest from terminal molars. So as you can see here, after the abutment is removed, there’s the tissue lateral of the lingual surface. And it appears that the implant was placed far apically and buccally. Now, what we did is the interposition CT graft. CT flap was mobilized to buccal service, and will flow into double layers to increase the thickness. And on top of that, we realized that the tissue from the lingual surface to bring it down is not adequate. Then we placed another soft tissue after epithilized from the ridge molar area, we were able to get good bulkness of the tissue with the migration of the gingival margin both buccally and lingually. This is after the treatment for six months. The third case is a 53-year-old female. She’s a housewife. And she complained number ten or tooth two two, metal show through, and she has a bad smell. The problem appeared to be there was some peri-implantitis is because of the probing death and the bleeding and the puss formation and the bone loss. And also margin recession. Buccal concavity. Papila loss. As well as poor implant positioning. The treatment plan involved disinfection of this implant. And we have to think in terms of the regeneration papila utilizing a submerged concept in this case. And in this case, for the mandible papila, we have to utilize modified VIP-CT. And esthetic procedure is to first control of inflammation. Second to improve the gingival contour marginally and papillarily. The third is to preserve or augment the papilla. The fifth is to provide a ridge augmentation at the same time. To score this case is a total score of 12, being the involvement of implant infection with peri-implantitis. And the implant was placed a little coronally, with buccal concavity, moderate marginal recession, moderate papila loss. And with one tooth that is symmetrical to the contralateral. And the color is not as pleasant. In this case, we have to think in terms of disinfecting the implant root. And regenerate the missing bone, as well as providing a soft tissue grafting for final esthetics, not only to correct the defect, but also to improve the esthetic and cover up the improper implant position. So in non-surgical procedures, we will utilize the titanium tipped scalar and q rat. At the same time providing the slow releasing gel. And I’ll utilize the laser to treat the implant service during the surgery. Now, during the surgery, the VIP-CT was utilized. This was to make to vertical releasing after elevation. Full thickness flap. We have to remove all the granulation tissue. Once it was degranulated, we have to sterilize first with hand instrument, then ultrasonic, then rotary, and then use chemical tetracycline. Then use optical laser. Decontamination. Then we place a bone graft. In this instance, bio-loss and bio-guide. Cover the bone graft. And the occlusal seal was provided with the VIP-CT from the palate. And this is after the flap is secured with a coronal positioning flap. This is the result one day after and followed by one year. The tissue is stabilized, both hard and soft, two years after the surgery. Similar instances like this, where we can also work on the one-piece implant, only we cannot guarantee to get ultimate papila height. However, we can change from the reverse architecture to a positive architecture. With a similar approach correcting the implant and regenerate what was missing, the bone and the soft tissue, by bone grafting, GBR procedure with membrane, and modified VIP-CT from the palate. In cases like this, not just papila loss, as well as marginal recession. And in multiple cases, we can correct it with the same procedure similar. So in conclusion, after looking at those three cases, now the inspiration from treating the periodonal deficiency is mainly, in this case, as you can see, that you have to have a good control of the tissue periodontally by nonsurgical procedure, which is called scaling and root planing You can regain the papila by natural process. And for papila preservation during a surgical procedure, you can cover the route, as well as the papila preserves utilizing one piece of soft tissue grafting. How about the implant complication? I showed this case in previous videos. It can also be utilized or achieved in improvement of esthetic result by just soft tissue grafting. This, I utilize a connective tissue graft harvested both from palate and rich molar area by making a pouch in the apical to coronal position. This was made– final restoration was made one year after, and was stabilized for one more year. And the vertical dimension of the soft tissue in this indentious area can be increased with the benefit of also covering the adjacent natural teeth and implant. And we will perform, this is called root coverage. This is called ridge augmentation and papila augmentation. So management implant complication and esthetic zone can be predictable if given the fact that the proper procedure was selected, and the patient has a desire to have the implant retained. Whether or not there’s a presence of an infection, the decontamination of the implant becomes essential in a lot of the cases. I would recommend that to utilize the blood supply from periosteum. So do not– if there’s no bone regeneration necessary to try to elevate the flap with periosteum retention. Now, if there’s a tissue integrity issue, you should try to pump up the tissue, to seal the holes of the defect. Use one soft tissue graft to enhance the tissue integrity, so that the future procedure can be utilized to place bone grafting, or even soft tissue grafting. Now for the third is a tissue layer. You have the thing in terms of the tissue has two layers. One is the periosteum layer. One is covering flap layer. To utilize that layer for management of the tissue defect. And to utilize the periosteum for good blood supply. Now the suture tie, lot of time when I suture the defect, I do not make the cut the first time. And instead, I utilized the tie– the tension of the first tie too tie it around another area to get optimal closure. The fifth is a soft tissue thickness. We can gain height by increasing the width. It’s something for a reminder in the implant complication cases. Now, for management of periodontal esthetics. It’s good to have good principles, and to look into the predictable way. And to preserve the natural dentition or to preserve the ridges. And on top of that, it has to fit in the patient desire. So the periodontal principle that I utilize is prevention and to have good focus on the esthetics And provide regeneration, together with the implant placement to support the natural dentition. And for implant surface contamination, I likely would utilize laser during the open face. Means during the surgical procedure, I would decontaminate the implant surface with laser. Thanks for your kind attention.

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