96 ce PERIODONTICS Test 163 dental CE today.com Manage ment of Plaque-Related Soft-Tiss ue Trauma

t is well known that an implant cannot a b be successful without adequate hard- Itissue support. However, the impor - tance of adequate soft tissue around an im - plant restoration is less frequently ac- knowledged, and problems with soft-tissue recession or breakdown can lead to compli - Ahmad Soolari, cations. Peri-implant soft tissue that is com - DMD, MS patible with the surrounding gingiva and mucosa is essential from an aesthetic point of view. Also, an implant-supported restora - tion benefits from thick soft-tissue support, since a thicker biotype is more resistant to mechanical and surgical insults, is less like - ly to recede, and has more tissue volume for Figures 1a and 1b. Preoperative photo and radiographic view of mandibular left first molar implant (No. 19) prosthetic manipula tion. 1,2 In addition, placed 3 years previously. Gingival deformity in the midfacial and proximal areas was observed. The thick gingiva can protect the underlying patient’s chief complaint was discomfort during daily procedures. The radiograph shows a well osseointegrated implant with some bone loss. Nafiseh Soolari, hard tissue and prevent aesthetic problems BA, CDRT in highly visible areas. This article details the treatment of a patient with on the midfa - Peri-implant soft tissue that is compatible with the surrounding cial aspect of a that had been placed 3 years previously. The implant was gingiva and mucosa is essential from an aesthetic point of view. adequate from the point of view of osseointe - gration, but the patient was unhappy be - cause of plaque buildup, food impaction, and lem. Previous attempts by other clinicians cular incision, which reached from the dis - discomfort around the implant. A mucogin - to correct this condition included laser tal of the second molar to the mesial of the gival deformity was diagnosed. This was cor - treatment, irrigation with a Waterpik (Wa - first premolar. The facial flap extended api - rected with a connective-tissue graft that re - ter Pik), and local antibiotic delivery, but all cally beyond the solved the concave area and gingival reces - had been unsuccessful. Replacement of the and was relaxed completely to affect coro - sion around the implant. This problem could crown and explantation of the implant had nal advancement. After a full-thickness flap have been avoided if tissue grafting had been also been proposed, but the patient had was raised, bone loss was noted up to the done initially, or if the treating clinician had rejected these solutions. third thread on the facial aspect of the noted the importance of high-quality kera - Clinical evaluation revealed an ac quired implant (Figure 2a). tinized peri-implant soft tissue. The result gingival deformity, caused by trauma and/or No attempt was made to perform bone was successful, and neither the crown nor plaque, associated with the facial aspect of grafting or detoxify the external surface of the implant had to be removed. the implant-supported crown (Figure 1a). the implant. It is the authors’ view that the The following case report details the The soft tissue had receded to the first thread mucogingival deformity was an etiology correction of the gingival deformity with a facially. A periapical radiograph also showed associated with this specific patient, not connective-tissue graft, which ensured the some bone loss around the implant, which with an infectious process; therefore, there long-term health of the peri-implant tissue. nevertheless remained stable (Figure 1b). was no need to decontaminate the implant To prevent the attachment loss from or apply bone grafts. Due to a severe defi - CASE REPORT continuing and to restore previously dam - ciency of soft-tissue volume, a thick graft A 45-year-old woman had received an im - aged areas, autogenous connective-tissue was harvested to fill in the large concave plant to replace the missing mandibular left grafting was performed to reconstruct the area associated with the facial aspect of the first molar tooth 3 years prior. She present - soft tissue into a normal configuration for implant (Figures 2b and 2c). Because the pre - ed with complaints of food impaction and a optimum health of the and molar area has the potential to provide “very uncomfortable condition” around her the associated restoration. No vertical inci - thicker grafts, which will help maintain dental implant, especially during normal sion was used to prepare the recipient site adequate vascularity and be less likely to hygiene procedures. She wished to be treat - for grafting. A No. 15c blade (Carbon Steel recede, 3,4 a thick (15 x 10 x 4 mm) graft of ed with a permanent solution to her prob - [Benco Dental]) was used for the initial sul - continued on page 98

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Management of Plaque-Related... a b c d continued from page 96 connective tissue was harvested from the maxillary left in the ca- nine/premolar region, adapted to the recipient site, and secured with single interrupted 4.0 Vicryl sutures (Poly - glactin 910, P3 [Ethicon]) (Figures 2d to 2f). The single-incision palatal harvest technique 4 was used for patient com - fort. The flap was positioned coronally Figure 2a. The site has been exposed Figure 2b. The maxillary Figure 2c. Subepithelial Figure 2d. A thick subepithelial for evaluation and treatment. Operative left palatal region was connective-tissue graft connective-tissue graft was to cover the harvested tissue com - view shows the dehiscence on the chosen to harvest harvested to correct harvested. pletely (Figure 2g). This corrected the facial aspect of the otherwise connective tissue. mucogingival deformity mucogingival defect and strengthened osseointegrated implant. (concave area associated with the the peri-implant tissue. facial aspect of After surgery, the patient was given mandibular implant). amoxicillin orally (500 mg, 3 times a day), ibuprofen (800 mg, 3 times a day, when necessary), methylprednisolone e f g to control swelling (Medrol Dosepak), and rinse (chlorhexidine gluconate, 0.12% oral rinse USP [Ac - clean, Henry Schein]) twice daily. The patient was very happy with the outcome. She stated that the area around her implant felt normal, and the problems with food impaction and dis - comfort during normal hy giene proce - dures were resolved permanently (Fig - Figure 2e. The harvested tissue has been Figure 2f. The graft was stabilized with 4-0 Figure 2g. Closure of flaps. ure 3). She was advised to replace the adapted to the recipient site. Vicryl sutures.

ensure that there is an adequate vol - min imal keratinized mucosa around Gingival recession on the midfacial aspect of an implant can ume of peri-implant soft tissue early the implant at the time of placement, in the process of implant treatment. 11 the threads of the implant may be - be attributed to several causes.... A 13-month study investigated come visible within a year or 2 after the relationship between the width of placement, and the restoration will keratinized mucosa and gingival in - appear longer, further contributing to existing bulky implant-supported blood supply to the peri-implant soft flam mation, presence of plaque, pock - poor aesthetics. 5 crown, but since her discomfort had dis - tissue is limited. Animal and human et depths, mucosal recession, and Immediate implant placement is appeared, she elected to keep the crown. clinical studies have shown that the marginal bone resorption. 12 The au - becoming a common practice in the peri-im plant gingiva may be more sus - thors 12 noted that an appropriate dental community to satisfy patients, DISCUSSION ceptible to infection and display a amount of keratinized gingiva assist - both aesthetically and functionally, Gingival recession on the midfacial stronger inflammatory response than ed in long-term maintenance and and to reduce treatment time. How - aspect of an implant can be attributed the gingiva around a natural tooth. 8,9 manage ment. In a 5-year study, ever, one of the complications associ - to several causes, including the facio - The area of infection around an im - Schrott et al 13 concluded that even ated with immediate implant place - lingual location of the implant with - plant has been reported to be larger patients who exercised good oral ment is midfacial gingival recession in the alveolar bone. Several factors, and to extend more apically versus the hygiene and received regular implant due to a missing buccal plate, implant including implant position, buccal natural dentition. 8 The absence of ade - maintenance therapy needed more positioning, inadequate width of ker - plate thickness, gingival tissue thick - quate peri-implant keratinized mu- than 2 mm of peri-im plant kera - atinized tissue, or a thin soft-tissue ness, and width of the keratinized cosa or attached mucosa has also been tinized mucosa to facilitate home profile of the patient. 1 The authors mucosa, have been found to influ - associated with higher plaque accu - care, prevent plaque accumulation, therefore recommend that soft-tissue ence the need for soft-tissue grafting. 1 mulation and gingival inflamma - minimize , and grafts should be used to prevent or Success in any kind of restorative tion. 10 Other reasons for ensuring ade - most importantly, reduce the likeli - correct midfacial mucosal recession— therapy, whether conventional or im - quate connective tissue around an hood of buccal soft-tissue recession. precisely what was done in this case plant-supported, must include an implant include: (1) the lower vascu - In addition to the many functional to correct gingival deformity. This intact midfacial soft-tissue profile larity of connective tissue (versus reasons for ensuring adequate soft tis - will result in predictable outcomes, and interproximal papillae. Soft-tis - mucosa) makes it less susceptible to sue around an implant, aesthetics is not just from an aesthetic point of sue deficiency can result in aesthetic bacterial infiltration, (2) connective improved. In patients with a thin gin - view, but also to ensure long-term and functional complications that are tissue is better at resisting damage gival biotype, the implant body or plat - function and comfort. unacceptable to a patient and make from trauma such as tooth brushing form may be come visible. Especially in Because it is well known that hard the area more susceptible to future or a retraction cord, and (3) attach - anterior areas, exposure of the titani - tissue inevitably recedes after implant tissue recession. 5 ment loss following implant place - um, a grayish ap pearance of the soft placement (and the soft tissue along Berglundh et al 6,7 noted that the ment is decreased. 5,11 The mucosa is tissues (titanium show-through), and with it), 14 it is preferable to manage a at tachment apparatus is different for easily traumatized and can be difficult inadequate papillae will result in aes - site proactively rather than waiting an implant versus a tooth, and the to maintain; it is therefore crucial to thetically inferior results. If there is until a problem develops. Connective-

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4. Lorenzana ER, Allen EP. The single-incision palatal Restorative Dent. 1987;7:36-51. harvest technique: a strategy for esthetics and Kennedy JE, Bird WC, Palcanis KG, et al. A longitudi - patient comfort. Int J Periodontics Restorative nal evaluation of varying widths of attached gin - Dent. 2000;20:297-305. giva. J Clin Periodontol. 1985;12:667-675. 5. Greenstein G, Cavallaro J. The clinical signifi - Rateitschak KH, Egli U, Fringeli G. Recession: a 4- cance of keratinized gingiva around dental year longitudinal study after free gingival grafts. J implants. Compend Contin Educ Dent. Clin Periodontol. 1979;6:158-164. 2011;32:24-31. 6. Berglundh T, Lindhe J, Ericsson I, et al. The soft Supplemental Reading: Autogenous-Free Soft-Tissue tissue barrier at implants and teeth. Clin Oral Grafts: Technique Implants Res. 1991;2:81-90. Laney JB, Saunders VG, Garnick JJ. A comparison of 7. Berglundh T, Lindhe J, Jonsson K, et al. The two techniques for attaining root coverage. J topography of the vascular systems in the peri - Periodontol. 1992;63:19-23. odontal and peri-implant tissues in the dog. J Clin Pennel BM, Tabor JC, King KO, et al. Free masticato - Periodontol. 1994;21:189-193. ry mucosa graft. J Periodontol. 1969;40:162- 8. Lindhe J, Berglundh T, Ericsson I, et al. Ex per i- 166. mental breakdown of peri-implant and periodon - Sullivan HC, Atkins JH. Free autogenous gingival tal tissues. A study in the beagle dog. Clin Oral grafts. I. Principles of successful grafting. Implants Res. 1992;3:9-16. Periodontics. 1968;6:121-129. 9. Salvi GE, Aglietta M, Eick S, et al. Reversibility of experimental peri-implant mucositis compared Supplemental Reading: Autogenous-Free Gingival with experimental in humans. Clin Oral Grafts: Clinical Studies Implants Res. 2012;23:182-190. Caffesse RG, Burgett FG, Nasjleti CE, et al. Healing 10. Chung DM, Oh TJ, Shotwell JL, et al. Significance of free gingival grafts with and without perios - of keratinized mucosa in maintenance of dental teum. Part I. Histologic evaluation. J Periodontol. implants with different surfaces. J Periodontol. 1979;50:586-594. 2006;77:1410-1420. Caffesse RG, Nasjleti CE, Burgett FG, et al. Healing 11. Mandelaris GA, Lu M, Rosenfeld AL. The use of a of free gingival grafts with and without perios - xenogeneic collagen matrix as an interpositional teum. Part II. Radioautographic evaluation. J Figure 3. At 3 years post-treatment, resolution of the gingival deformity is apparent. The soft-tissue graft to enhance peri-implant soft-tis - Periodontol. 1979;50:595-603. patient’s chief complaint was resolved, and there was no further discomfort experienced sue outcomes: a clinical case report and histo - Dorfman HS, Kennedy JE, Bird WC. Longitudinal eval - during daily oral hygiene. An apparent creeping attachment phenomenon is also evident. logic analysis. Clinical Advances in Periodontics. uation of free autogenous gingival grafts. A four 2011;1:193-198. year report. J Periodontol. 1982;53:349-352. 12. Kim BS, Kim YK, Yun PY, et al. Evaluation of peri- Jahnke PV, Sandifer JB, Gher ME, et al. Thick free gin - implant tissue response according to the pres - gival and connective tissue autografts for root tissue grafting, still seen as the gold implant crown or the entire implant ence of keratinized mucosa. Oral Surg Oral Med coverage. J Periodontol. 1993;64:315-322. standard for correcting mucogingival (explantation). However, the location Oral Pathol Oral Radiol Endod. 2009;107:e24- Matter J. Creeping attachment of free gingival grafts. 15 e28. A five-year follow-up study. J Periodontol. deformities, should be done when of the implant in a molar region meant 13. Schrott AR, Jimenez M, Hwang JW, et al. Five-year 1980;51:681-685. there is minimal peri-implant soft tis - that it bore strong occlusal forces, and evaluation of the influence of keratinized mucosa Miller PD Jr. Root coverage using the free soft tissue on peri-implant soft-tissue health and stability autograft following citric acid application. III. A sue; the additional tissue will support this may have contributed to the loss around implants supporting full-arch mandibular successful and predictable procedure in areas of the implant and prevent functional of the facial bone and already thin soft fixed prostheses. Clin Oral Implants Res. deep-wide recession. Int J Periodontics 2009;20:1170-1177. Restorative Dent. 1985;5:14-37. and aesthetic problems from develop - tissue (although it was clearly not the 14. Albrektsson T, Zarb G, Worthington P, et al. The Miller PD Jr. Root coverage with the free gingival ing. When performed at stage-2 sole cause, since the problem was long-term efficacy of currently used dental graft. Factors associated with incomplete cover - implants: a review and proposed criteria of suc - age. J Periodontol. 1987;58:674-681. cess. Int J Oral Maxillofac Implants. 1986;1:11- Mörmann W, Schaer F, Firestone AR. The relationship 25. between success of free gingival grafts and 15. Camelo M, Nevins M, Nevins ML, et al. Treatment transplant thickness. Revascularization and ...it is preferable to manage a site proactively rather than of gingival recession defects with xenogenic col - shrinkage—a one year clinical study. J lagen matrix: a histologic report. Int J Perio - Periodontol. 1981;52:74-80. dontics Restorative Dent. 2012;32:167-173. waiting until a problem develops. 16. Speroni S, Cicciù M, Maridati P, et al. Clinical Supplemental Reading: Connective-Tissue Grafts investigation of mucosal thickness stability after Borghetti A, Louise F. Controlled clinical evaluation of soft tissue grafting around implants: a 3-year ret - the subpedicle connective tissue graft for the rospective study. Indian J Dent Res. coverage of gingival recession. J Periodontol. implant surgery, these grafts are sta - resolved without occlusal therapy). 2010;21:474-479. 1994;65:1107-1112. 17. Capri D. Soft tissue management around dental Langer B, Langer L. Subepithelial connective tissue ble over the long term (3 years in a The site was therefore inadequate to implants. In: Dibart S, Karima M. Practical Peri - graft technique for root coverage. J Periodontol. study performed by Speroni et al 16 ). resist recession, soft-tissue complica - odontal Plastic Surgery. Ames, IA: Blackwell 1985;56:715-720. 2 Publishing; 2006:71-98. Nelson SW. The subpedicle connective tissue graft. Fu et al proposed a “management tions, and plaque buildup. A bilaminar reconstructive procedure for the cov - triad” for peri-implant soft tissue. Supplemental Reading: for Implants erage of denuded root surfaces. J Periodontol. Cosyn J, Sabzevar MM, De Bruyn H. Predictors of 1987;58:95-102. This involves choosing the appropri - CONCLUSION inter-proximal and midfacial recession following ate implant position and angulation, To prevent soft-tissue complications single implant treatment in the anterior maxilla: a implant design, and prosthetic design associated with dental implants, it is multivariate analysis. J Clin Periodontol. Dr. Ahmad Soolari is a Diplomate of American 2012;39:895-903. Board of . He has a Certificate Esposito M, Maghaireh H, Grusovin MG, et al. Soft to promote a thick gingival biotype. recommended that soft-tissue graft - in Periodontics from the Eastman Dental 1 tissue management for dental implants: what are Hsu et al presented a decision-mak - ing be done prior to (or at) the time of the most effective techniques? A Cochrane sys - Center and a MS degree from the University of ing model to prevent midfacial implant placement to preserve the tematic review. Eur J Oral Implantol. 2012;5:221- Rochester, Rochester, New York. He is clinical 17 238. associate professor at the University of mucosal recession. Capri recently normal gingival anatomy and to pre - Silverstein LH, Kurtzman D, Garnick JJ, et al. Maryland, Dental School in Baltimore, Md. Dr. provided an excellent review of differ - vent complications with undesirable Connective tissue grafting for improved implant Soolari operates a specialty practice in the esthetics: clinical technique. Implant Dent. ent techniques to increase the peri- outcomes. ! Silver Spring and Potomac area of Mon- 1994;3:231-234. tgomery County, Md. He can be reached at implant gingiva. Simons AM, Baima RF. Free gingival grafting and vestibuloplasty with endosseous implant place - [email protected]. The present case highlights the Acknowledgement ment: clinical report. Implant Dent. 1994;3:235- importance of correct diagnosis and The authors thank Jennifer P. Bal - 238. Disclosure: Dr. Soolari reports no disclosures. Simons AM, Darany DG, Giordano JR. The use of free proactive treatment. This patient was linger, ELS, for assistance in drafting gingival grafts in the treatment of peri-implant treated for a year with no relief of her the text for publication. soft tissue complications: clinical report. Implant Ms. Nafiseh Soolari is at the University of Dent. 1993;2:27-30. Maryland, School of Public Health. She is a uncomfortable situation because the Tsuda H, Rungcharassaeng K, Kan JY, et al. Peri- 5FOCUS consultant and practice success spe - diagnosis was incorrect. An infectious References implant tissue response following connective tis - 1. Hsu YT, Shieh CH, Wang HL. Using soft tissue sue and in conjunction with imme - cialist with expertise in team building, staff cause for her problems was assumed, graft to prevent mid-facial mucosal recession fol - diate single-tooth replacement in the esthetic training, marketing, and overall practice man - so she was treated with antibiotics, lowing immediate implant placement. J Int Acad zone: a case series. Int J Oral Maxillofac agement. She started her dental career in a Periodontol. 2012;14:76-82. Implants. 2011;26:427-436. periodontal office, first as a dental assistant, local delivery of an anti-infective agent 2. Fu JH, Lee A, Wang HL. Influence of tissue bio - where she became a Certified Dental (Arrestin), anti-infective rinse, nonsur - type on implant esthetics. Int J Oral Maxillofac Supplemental Reading: Gingival Grafting Radiation Technologist (CDRT) and then as a Implants. 2011;26:499-508. Freedman AL, Green K, Salkin LM, et al. An 18-year practice manager. She can be reached at gical soft-tissue management, laser 3. Reiser GM, Bruno JF, Mahan PE, et al. The subep - longitudinal study of untreated mucogingival [email protected]. therapy, and Waterpik. One clinician ithelial connective tissue graft palatal donor site: defects. J Periodontol. 1999;70:1174-1176. anatomic considerations for surgeons. Int J Maynard JG. The rationale for mucogingival therapy had even recommended removal of the Periodontics Restorative Dent. 1996;16:130-137. in the child and adolescent. Int J Periodontics Disclosure: Ms. Soolari reports no disclosures.

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