Symphony of Solutions: Unraveling Soft Tissue Dilemmas in Aesthetic Zone Implants
In contemporary implant dentistry, the focal point extends beyond mere osseointegration and bone regeneration (Dursun E et al; 2018). Patients now desire not only functional restoration but also implant rehabilitations that showcase natural aesthetics. A prevalent biological complication in the esthetic zone is mucosal recession, often attributed to various causes, with implant malpositioning notably standing out (Shraddha P Kochar et al; 2022). Soft tissue recession consistently precedes bone dehiscence, emphasizing the need for corrective measures, not just for aesthetic improvement but also to prevent or rectify the exposure of rough implant surfaces, a condition with potential peri-implantitis implications.
In this context, soft tissue augmentation emerges as a pivotal determinant for achieving a durable and aesthetically pleasing outcome over the long term. The spectrum of treatment options includes sophisticated techniques such as coronally advanced flaps (CAF), the tunnel technique (TT), or strategic implant submergence, with or without concurrent prosthetic modifications (Igor Ashurko et al; 2021). Moreover, a diverse array of soft tissue graft donor sites presents itself, each endowed with distinctive advantages (Robert A Levine et al; 2014).
Surgical soft tissue management in implant reconstruction involves two primary categories: augmentation for keratinized tissue width and enhancement of soft tissue thickness/volume (Daniel S. Thoma et al; 2021). Techniques aimed at augmenting keratinized tissue focus on establishing a band attached to the periosteum, deepening the vestibular fornix, and enhancing patient home care and plaque control. Conversely, soft tissue thickness augmentation techniques concentrate on creating or restoring supracrestal soft tissues around the implant, elevating their thickness and height from the bone crest to the mucosal margin using diverse connective tissue grafts. This is crucial for achieving a natural emergence profile in prosthetic restoration and ensuring aesthetically pleasing results, often implemented in anterior areas.
Strategic soft tissue management occurs before implant placement, concurrently with implant placement, and during second-stage surgery (Tarnow DP et al; 2014). Notably, post-prosthetic restoration, soft tissue augmentation can address complications that may arise, underscoring its versatility and relevance throughout the implant reconstruction process.
Precise implant placement emerges as a key factor in the emergence of mucosal recession, emphasizing the adverse impact of buccal implant position, with an approximately 35-fold increased risk of recession development (Stephen T. Chen et al; 2023). In cases where the implant shoulder extends beyond the ridge contour and adjustments through prosthetic modifications are impractical, treating such situations is deemed irrational. While attention often centers on bucco-oral positioning, the vertical placement of the implant is equally critical. For bone level implants, positioning the implant shoulder 3-4 mm below the anticipated mucosal margin is recommended, with case analysis utilizing analog or digital mock-ups as a prudent step.
The peri-implant phenotype, introduced recently, highlights the importance of both soft and hard tissue dimensions ( Cho-Yong Lin et al; 2022). A thin peri-implant phenotype, characterized by limited mucosal thickness, soft tissue height, bone thickness, and buccal/oral bone plate dimensions, underscores the intricate interplay between these factors. Notably, soft tissue thickness appears to exert a more substantial influence on mucosal level than bone thickness in the short term.
Peri-implant soft tissue deficiency (PSTDef) is acknowledged as a potential concern, detectable as a grayish shimmer or dark shadow buccal to the implant (Giovanni Zucchelli et al; 2019). Correction of PSTDef is recommended before or during uncovering the implant due to enhanced accessibility. The selection between connective tissue grafts (CTG) and acellular dermal matrices (ADM) for modifying peri-implant phenotype depends on clinician preference, experience, and local factors.
The debate between coronally advanced flaps (CAF) and tunnel techniques (TT) for addressing periimplant soft tissue dehiscence (PSTDeh) lacks conclusive scientific evidence (Lorenzo Tavelli et al; 2023). While CAF may offer better access and flap mobility, TT minimizes scar formation and preserves papilla integrity. Additionally, re-submerging the implant by removing the reconstruction presents a third option, potentially contributing to keratinized mucosa gain.
In soft tissue management, autologous grafts remain the gold standard, with de-epithelialized connective tissue grafts (deepCTG) and tuberosity grafts (tuberCTG) gaining popularity in the past decade (Igor Ashurko et al; 2021).Their specific characteristics make them suitable for mucosal thickness (MT) and keratinized mucosa (KM) augmentation; however, careful consideration of potential esthetic implications, such as keloid-like healing or graft exposure, is crucial.
In conclusion, addressing mucosal recession and peri-implant soft tissue complications involves a comprehensive understanding of implant placement nuances, the peri-implant phenotype, and the choice of grafting techniques. Clinical recommendations include meticulous assessment of crownwidth to crown-length ratios, consideration of treatment predictability for shallow recessions, and a nuanced approach to graft selection based on specific clinical scenarios and characteristics.
