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Soft Tissue Grafting to Improve the Attached Mucosa at Dental Implants: a Review of the Literature and Proposal of a Decision Tree

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Soft Tissue Grafting to Improve the Attached Mucosa at Dental Implants: a Review of the Literature and Proposal of a Decision Tree QUINTESSENCE INTERNATIONAL IMPLANTOLOGY Mario Bassetti Renzo Bassetti Soft tissue grafting to improve the attached mucosa at dental implants: A review of the literature and proposal of a decision tree Mario Bassetti, DMD, Dr med dent1*/Regula Kaufmann, DMD, MAS, Dr med dent2/Giovanni E. Salvi, DMD, Prof Dr med dent3/Anton Sculean, DMD, MS, PhD, Prof Dr med dent4/Renzo Bassetti, DMD, MAS, Dr med dent5* Background: Scientific data and clinical observations appear indicate that ideally, soft tissue conditions should be opti- to indicate that an adequate width of attached mucosa may mized by various grafting procedures either before or during facilitate oral hygiene procedures thus preventing peri-implant implant placement or as part of stage-two surgery. In cases, inflammation and tissue breakdown (eg, biologic complica- where, despite insufficient peri-implant soft tissue condition tions). Consequently, in order to avoid biologic complications (ie, lack of attached mucosa or movements caused by buccal and improve long-term prognosis, soft tissue conditions should frena), implants have been uncovered and/or loaded, or in be carefully evaluated when implant therapy is planned. At cases where biologic complications are already present (eg, present the necessity and time-point for soft tissue grafting mucositis, peri-implantitis), the treatment appears to be more (eg, prior to or during implant placement or after healing) is difficult and less predictable. Conclusion: Soft tissue graft- still controversially discussed while clinical recommendations ing may be important to prevent peri-implant tissue break- are vague. Objectives: To provide a review of the litera- down and should be considered when dental implants are ture on the role of attached mucosa to maintain peri-implant placed. The presented decision tree may help the clinician to health, and to propose a decision tree which may help the clin- select the appropriate grafting technique. (Quintessence Int ician to select the appropriate surgical technique for increasing 2015;46:499–510; doi: 10.3290/j.qi.a33688) the width of attached mucosa. Results: The available data Key words: peri-implant keratinized attached mucosa, peri-implantitis, soft tissue recession The soft tissue around teeth is subdivided by definition the mucogingival junction (Fig 1). The gingival width into gingiva and mobile alveolar mucosa. The border- can vary inter-individually between 1 mm and 9 mm.1 line between alveolar mucosa and gingiva is termed In contrast, the terminology of the peri-implant soft tis- sue in the literature is inconsistent. 1 Lecturer, Department of Periodontology, University of Bern, Bern, Switzerland. There are various reasons to distinguish the peri- 2 Private Practice, Grosswangen, Switzerland. 3 Associate Professor, Department of Periodontology, University of Bern, Bern, implant mucosa from the gingiva around teeth: Switzerland. • The periodontal fibers in teeth run perpendicular to 4 Professor in Chair, Department of Periodontology, University of Bern, Bern, Switzerland. the root surface and insert into the root cementum 5 Lecturer, Department of Oral and Maxillofacial Surgery, Lucerne Cantonal Hos- pital, Lucerne, Switzerland. (Sharpey’s fibers), while the peri-implant connective *Both authors contributed equally to the manuscript. tissue fibers run in a parallel direction to the implant Correspondence: Dr Renzo Bassetti, Department of Oral and Maxillofa- or abutment surface and do not attach to the cial Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne, Switzerland. Email: [email protected] implant.2,3 VOLUME 46 • NUMBER 6 • JUNE 2015 499 QUINTESSENCE INTERNATIONAL Bassetti et al in some cases, despite the presence of keratinization, the peri-implant mucosa is not attached to the underly- ing bone. This can occur in cases of slightly higher located peri-implant soft tissue, when the junction free gingiva between KM and lining mucosa is situated more coro- nally in relation to the peri-implant bone margin.8 attached gingiva keratinized mucosa At present the necessity and time-point for soft tis- mucogingival junction sue grafting (eg, prior to or during implant placement alveolar mucosa or after healing) are still controversially discussed in the literature, and clinical recommendations are vague. The purposes of this article are to present a review of the literature on the role of the attached mucosa (AM) in the maintenance of peri-implant health, and to propose a decision tree which may help the clinician to select the appropriate surgical technique for increasing Fig 1 Schematic illustration of soft tissue structures around teeth the width of AM. and implants. REVIEW OF THE LITERATURE • The peri-implant connective tissue consists of a lower number of fibroblasts and a greater amount The role of a certain width of keratinized tissue (KT) for of collagen fibers and has a comparable structure to preserving periodontal health is still controversially dis- that of scar tissue.2,4 cussed in the literature. Observations from a clinical study • The junctional epithelium around dental implants is have indicated that, even with supervised oral hygiene, more permeable than that around teeth.5 all sites with < 2 mm of KT showed clinical signs of inflam- • The gingiva has a higher number of blood vessels mation, whereas 80% of sites showing ≥ 2 mm of KT and compared to peri-implant mucosa.6 attached tissue remained healthy. Based on these find- ings, the authors have concluded that ≥ 2 mm of KT is It seems that the presence of non-elastic collagen fibers necessary to maintain the health of periodontal tissues.11 in the underlying connective tissue is responsible for On the other hand, another investigation including the existence of keratinized tissues while most fibers 16 subjects has failed to show any differences in terms from the periodontal ligament space are non-elastic of clinical signs of inflammation, irrespective of whether (eg, collagen) fibers. Therefore, around teeth, even fol- the soft tissue surrounding the teeth displayed a band lowing its complete surgical excision, a narrow band of of KT width varying from < 1 mm to ≥ 2 mm.12 Thus, at gingiva will, in most cases, reform.7 In contrast, implants present, it is generally accepted that, around natural can be surrounded by keratinized mucosa (KM) as well teeth, the presence of a certain width of attached gin- as by mobile alveolar mucosa.8 An experimental study giva is not necessary to maintain periodontal health.13-15 in monkeys revealed that the specificity of epithelium However, around dental implants, the potential role (keratinized or non-keratinized epithelium) appears to of an adequate width of keratinized/attached mucosa be influenced by the type of the underlying connective (KAM) on the long-term clinical stability is still a matter tissue;9 ie, the connective tissue, harvested from an area of debate.16-28 In two human studies in totally edentu- covered by keratinized epithelium and transplanted lous patients, reconstructed with screw-retained fixed into an area covered by non-keratinized epithelium, partial dentures, no correlation between implant suc- has the potential to induce keratinization.9,10 However, cess and the presence of KAM was detected.16,21 Two 500 VOLUME 46 • NUMBER 6 • JUNE 2015 QUINTESSENCE INTERNATIONAL Bassetti et al other human studies failed to support the concept that In many clinical situations following teeth extrac- an adequate width of KM is essential in order to main- tions, horizontal and vertical bone resorption occurs tain a clinical healthy peri-implant soft tissue condi- due to the inactivity atrophy.46-48 This process is often tion.17,26 Moreover, in a study in dogs, no differences accompanied by a coronal displacement of the muco- could be detected in terms of gingival recession or loss gingival junction.49,50 Since implant surgery frequently of attachment, independent of the presence or absence includes one-stage or two-stage bone augmentation of AM and the width of KM. Grafting of gingival tissue procedures, an additional displacement of the muco- increased the width of KAM, but did not additionally gingival junction may occur.51,52 Therefore, in order to improve the condition of peri-implant soft tissue.24 On optimize the width of KAM, different soft tissue aug- the other hand, three earlier studies have indicated that mentation protocols have been suggested: the absence of KAM around dental implants increases • as preliminary pre-implantation intervention before the susceptibility of inflammation and adverse peri- implant placement implant soft and hard tissue reactions.18,25,28 Accord- • as part of the implant placement surgery ingly, based on the limited evidence present at that • as part of the stage-two surgery (re-entry) time, earlier reviews identified insufficient reliable evi- • when the implant is already uncovered and eventu- dence regarding an association between the absence ally loaded. of KM and peri-implant disease.19,20,23 In contrast, very recent publications suggest that the absence of an The first three of the above-mentioned protocols seem adequate width of KAM around dental implants may to result in more predictable outcomes, compared to lead to increased levels of plaque accumulation,29-33 interventions after loading. In most cases in which an higher rates of mucositis,29,31,32,34,35 higher risk of peri- intervention at the peri-implant soft tissue is required implant alveolar bone loss,34,36 as well as soft tissue after loading, esthetic problems or biologic complica- recession 29,32,33,36,37 and clinical attachment loss.37 In tions like mucositis or peri-implantitis are already pres- addition, the width of peri-implant KAM seems to have ent. Moreover, the data on the indication of various an influence on immunologic parameters.35,38 There- surgical soft tissue augmentation techniques depend- fore, by implication, better outcomes in terms of soft ing on the existing soft tissue (connective tissue graft and hard tissue stability and esthetics might be [CTG], free gingival graft [FGG], combination of both) expected in the presence of an adequate width of peri- are scarce.53-56 implant KAM.
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