The International Journal of Periodontics & Restorative Dentistry © 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 227 Peri-Implant Mucosal Creeping: Two Case Reports Carlos Parra, DDS1 Periodontal plastic surgery is de- Diego Capri, DDS2 fined as any surgical procedure performed to correct or eliminate anatomical, developmental, or trau- matic deformities of the gingiva or alveolar mucosa.1 An adequate band While creeping attachment in natural teeth has been reported in the literature for of keratinized tissue around teeth tra- decades, the same phenomenon around dental implants is a new concept. This ditionally has been advocated.2 Nev- article describes two implant cases treated with free gingival autograft with follow- ertheless, when good oral hygiene is up at 18 and 30 months. Progressive coronal creeping of the mucosal margin was performed and inflammation is con- observed covering the implant and abutment surfaces postoperatively. This report demonstrates that mucosal creeping around implants may occur after peri-implant trolled, a very narrow or absent band plastic surgical procedures, further improving the final outcomes of therapy. of attached gingiva is still compatible Int J Periodontics Restorative Dent 2018;38:227–233. doi: 10.11607/prd.3013 with gingival health and no progres- sion of soft tissue recession.3–6 In cases of subgingival restora- tions, an adequate band of keratin- ized gingiva was found to be a factor in preventing inflammation and re- cession.7,8 In the field of implantol- ogy, the need for keratinized mucosa is controversial. While two systematic reviews have concluded that there is currently not enough evidence to determine whether an increase in ke- ratinized mucosa is beneficial for the patient,9,10 the most recent systematic reviews on the topic concluded that the absence of an adequate zone of keratinized mucosa is associated with more plaque accumulation, tis- 1 Clinical Assistant Professor, Department of Periodontics, Texas A&M University College sue inflammation, mucosal recession, of Dentistry, Dallas, Texas, USA; Former Postgraduate Resident, Department of and attachment loss.11 Moreover, the Periodontology, Tufts University School of Dental Medicine, Boston, Massachusetts, USA. 2Private Practice, Periodontics and Dental Implants, Bologna, Italy. presence of an adequate band of ke- ratinized mucosa has been shown to Correspondence to: Dr Carlos Parra, Texas A&M University College of Dentistry, be related to peri-implant health.12 Department of Periodontics, 3302 Gaston Avenue, Dallas, TX 75246, USA. The main indications for the treat- Fax: 214-874-4563. Email: [email protected] ment of mucosal recession around ©2018 by Quintessence Publishing Co Inc. implants are similar to the indications Volume 38, Number 2, 2018 © 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 228 for treatment around teeth, with the cases where peri-implant plastic sur- Presurgical Phase obvious exclusions of tooth sensitiv- gery was performed, enhancing the Oral hygiene instructions were given ity and risk of caries. Therefore, sur- quality and quantity and improving and full-mouth debridement was gical treatment of recession around the esthetics of the soft tissues sur- performed. After reevaluation, no implants may be performed for es- rounding the implants. It confirms the clinical improvements were noted thetic reasons, to prevent further findings of Pereira-Neto et al24 and on that tooth. A free soft tissue au- recession, for cleansability of the re- adds further speculation to the bio- tograft was recommended with the construction, to establish and main- logic hypothesis regarding coro- primary goals of improving the quan- tain biologic health, and to create or nal creeping of keratinized mucosa tity and quality of peri-implant soft augment keratinized tissue.13–15 around implants. tissues and possibly achieving partial Peri-implant plastic surgery fo- peri-implant recession coverage. cuses on harmonizing peri-implant structures by means of hard and soft Case Reports Surgical Phase tissue engineering and includes en- Two carpules of 2% lidocaine hancement of bone structure and Case 1 (Xylocaine) with 1:100,000 epineph- soft tissue.16 Peri-implant plastic rine were given as maxillary left surgery also aims to create a peri- A 46-year-old man with noncontribu- buccal infiltrations and maxillary left implant keratinized mucosa and in- tory medical history was referred by greater palatine block. Bone sound- terimplant soft tissue height. his general dentist to assess the peri- ing was performed to identify the Creeping attachment is defined implant mucosal recession and lack of subjacent bony architecture. as postoperative migration of the keratinized mucosa of the dental im- At the recipient site, a partial- gingival margin in a coronal direc- plant in the position of the maxillary thickness flap preserving the un- tion over portions of a previously left first molar (Fig 1a). The patient’s derlying periosteum was performed denuded root.17 It occurs during the chief complaint was purely esthetic as described by Miller29 with two second month,18 continues for 12 due to exposure of the metal collar oblique incisions, one mesial and months after surgery, and seems not of the implant. On clinical examina- another distal, 3 mm long on the im- to follow a constant progression pat- tion, the implant presented probing plant at the site of the maxillary left tern.19,20 Nevertheless, reports have depths of 2 to 5 mm with bleeding on first molar, extending 9 mm apically. shown that creeping attachment probing, 3 mm of mucosal recession, A 6-mm bony dehiscence on the may continue to progress beyond lack of keratinized tissue, a high frenal buccal side was observed (Fig 1c). the first postoperative year.21–24 pull, and scarring from a previously At the donor site, a second Various amounts of creeping at- failed free soft tissue autograft. surgical site was created on the tu- tachment in natural teeth have been The radiographic examination berosity area. A 20 × 8-mm epithe- reported in the literature, with an av- using bitewings and periapical ra- lialized free gingival autograft of 1.5 erage ranging from 0.36 to 0.89 mm, diographs showed slight bone loss to 2 mm thick was harvested using in follow-up periods from 1 to 27 on the mesial side and up to 30% a Bard-Parker #15 blade. The donor years.18–20,22,23,25–28 Although one re- bone loss on the distal side of the wound was sutured with Vicryl 5-0 port described the coronal migra- implant (Fig 1b). (Ethicon, Johnson & Johnson) as a tion of the mucosal margin around The implant (3i Certain, 6 mm continuous suture. A periodontal implants, no measurements were diameter × 10 mm length) had been dressing (Coe-Pak, GC) was applied. mentioned other than the number of placed 9 years earlier. A free gingi- The epithelialized free gingival implant threads covered.24 val autograft was also attempted at autograft was trimmed and adapted The present case report de- that time, with suboptimal results. A over the recipient bed, covering the scribes the coronal migration of the screw-retained porcelain-fused-to- implant dehiscence. Monocryl 5-0 peri-implant mucosal margin in two metal restoration was delivered. (Ethicon, Johnson & Johnson) was The International Journal of Periodontics & Restorative Dentistry © 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 229 used to place simple interrupted sutures and an X-sling suture to se- cure the graft in the recipient bed (Fig 1d). A periodontal dressing (Coe-Pak, GC) was also applied cov- ering the free soft tissue autograft. a b Postoperative Care The patient was given 600 mg of ibuprofen (Advil, Pfizer) following the surgery and was instructed to take it every 8 hours for the first 2 days, and then as needed. The pa- tient was also instructed to rinse twice a day for 30 seconds with c d 0.12% chlorhexidine (Peridex, 3M ESPE) starting 24 hours after the sur- gery for 14 days. Follow-up At the 1-week follow-up, the peri- odontal dressing was gently removed, and the wound was deli- e f cately debrided with gauze soaked in Peridex. The palatal donor sutures were removed. A residual recession of 3 mm was present. At 14 days, the wound was again debrided with a gauze soaked in Peridex and the remaining sutures on the recipient area were removed. g h Recession was still present, although Fig 1 Case 1. (a) Baseline clinical photograph showing a lack of keratinized tissue, peri- it was narrower in a mesiodistal di- implant mucosal recession, and frenal pull. (b) Periapical radiograph showing mesial and mension (Fig 1e). distal implant bone levels. (c) Bed preparation. Note the implant bony dehiscence, partially A localized supragingival de- covered by the periosteum. The frenum has been dissected. (d) Graft sutured to ensure passive adaptation on the recipient bed. Note the tuberosity at the donor site. (e) Clinical bridement was performed every 2 view at 2 weeks postoperative. Note residual recession of 2.5 mm. (f) At 6 weeks postop- weeks for the first month and ev- erative, recession was reduced but still present. (g) At 3 months postoperative, recession was reduced and the implant collar was partially covered. (h) At 18 months postoperative, ery 2 months for the subsequent 6 complete implant coverage was achieved. months using an ultrasonic scaler with a plastic-coated insert (SoftTip, Denstply) and finishing with a rub- ber cup (Dentsply) on a low-speed The postoperative plaque a roll technique in a coronal direc- handpiece.