Management and prevention of soft tissue complications in implant dentistry

Abstract

The management and prevention of soft tissue complications is of key importance in modern implant dentistry and influences biologic and esthetic outcomes. The assessment of the soft tissue conditions from a quantitative and qualitative perspective should, therefore, be part of the overall treatment plan. Such an assessment dictates a potential indication as well as an ideal time point for additional soft tissue management. A proper risk assessment and management of the soft tissues at the planned implant site are of key importance prior to any implant-related surgery. Cases with peri-implant soft tissue complications generally involve: (a) a lack of attached and keratinized mucosa; (b) insufficient volume; (c) development of mucosal dehiscences; or (d) a combination of (a), (b), and (c). In case of soft tissue deficiencies, these should be addressed as early as possible to increase the predictability of the surgical interventions. This article reviews the main causes for peri-implant soft tissue complications and presents different therapeutic options for the management of various clinical scenarios.

Keywords: implant mucosa augmentation; peri-implant biology; peri-implant mucosa; soft tissue complications.

FIGURE 1

Risk scale of soft tissue management before, during, and after implant placement. AM, attached mucosa; Aug, augmentation

FIGURE 2

Clinical case of soft tissue management simultaneous to ridge preservation and in combination with implant placement. A, Patient's initial situation. B, Periapical radiograph of tooth 21. C, Alveolar ridge preservation. D, Palatal sub‐epithelial connective tissue graft. E, Sealing of the socket in ridge preservation. F, Post‐operative healing after 6 months. G, Cone‐beam computed tomography scan of healed site 21. H, Implant placement. I, Soft tissue grafting with volume‐stable xenogeneic collagen matrix. J, Post‐operative healing after 2 weeks. K, Abutment connection with U‐Flap. L, Emergence profile of implant 21. M, Periapical radiograph of osseointegrated implant 21. N, Patient's final situation after receiving the implant supported‐restoration

FIGURE 3

Clinical case of soft tissue management prior to implant and guided bone regeneration surgery. A‐B, Patient's initial situation. C, Minimally‐invasive flap combined with tunneling technique. D,Palatal sub‐epithelial connective tissue graft. E, Suturing with resin bonded provisional. F, Post‐operative healing after 8 weeks. G, Guided bone regeneration simultaneous to implant placement. H, Flap closure with sutures. I, Abutment connection with minimal U‐Flap. J, Abutment connection with healing abutment. K, Emergence profile of the implant. L, Seven year follow‐up

FIGURE 4

Clinical case of soft tissue management prior to tooth extraction and prior to block bone graft and posterior implant placement. A‐B, Patient's initial situation. C, Orthodontic extrusion on tooth 12 after 6 months. D, Extraction of tooth 12. E, Palatal subepithelial connective tissue graft stabilization. F, Post‐operative healing after 6 weeks. G, Bone augmentation with an autogenous block bone graft. H, Post‐operative healing after 4 months. I, Implant placement 11. J, Post‐operative healing after 3 months. K, Implant‐supported restoration 11 with a distal cantilever 12. L, Clinical situation after y ears of delivery of the restoration

FIGURE 5

Clinical case of soft tissue management simultaneous to implant placement and guided bone regeneration. A‐B, Patient's initial situation. C, Immediate implant placement after extraction of tooth 11. D, Guided bone regeneration performed buccal to implant 11. E, Collagen membrane adapted to seal the socket. F, Sub‐epithelial connective tissue graft. G, Partial thickness pouch buccal to the implant with autogenous graft. H, Post‐operative healing after 3 months. I, Implant‐supported provisional restoration. J, Conventional open tray impression of implant 11. K‐L, Implant‐supported restoration on 11 after one year follow‐up

FIGURE 6

Clinical case of soft tissue management within the implant healing phase, after implant placement and before abutment connection. A, Patient's initial situation with missing tooth 21. B, Implant placement without augmentation on 21. C, Post‐operative healing after one month. D, Placement of a sub‐epithelial connective tissue graft buccal and occlusal to the implant. E, Primary wound closure with sutures. F‐G, Post‐operative healing after 2 months. H, Implant‐supported restoration on 21. I, Clinical situation at three year follow‐up

FIGURE 7

Clinical case of soft tissue management at abutment connection. A, Patient's initial situation. B, Partial thickness incision buccal to placed implant 24. C, Apical suturing of the flap. D, Healing abutment placed on implant 24. E, Free gingival graft from the palate. F, Trimming of the free gingival graft. G‐H, Stabilization of the free gingival graft with sutures. I, Post‐operative healing after 4 weeks. J, Clinical situation after 2 years of follow‐up

FIGURE 8

Clinical case of soft tissue management after the delivery of the implant reconstruction. A, Patient's initial situation with implant recession on 21. B, Patient's initial situation with reduced buccal volume. C‐D, Implant restoration removed. E, Implant abutment polished. F, Modification of implant‐supported restoration 21. G, Tunneling procedure around implant mucosa and adjacent teeth. H, Palatal sub‐epithelial connective tissue graft. I, Placement of anchorage sutures. J, Stabilization of graft inside the tunnel with anchorage sutures. K, Coronal advancement of the tunnel with sutures. L, Clinical situation after 2 years follow‐up

FIGURE 9

Clinical case of soft tissue management after the delivery of the implant reconstruction. A, Patient's initial situation with soft tissue margin discrepancy. B‐C, Removal of the implant‐supported restoration 11. D, Healing after 4 weeks without the restoration 11. E, Soft tissue volume deficiency on site 11. F, Stabilization of a sub‐epithelial connective tissue graft buccal and occlusal to the implant. G, Primary wound closure with sutures. H, A resin bonded bridge cemented on tooth 11. I, Clinical situation after 3 year follow‐up