Vertical soft tissue augmentation to treat implant esthetic complications: A prospective clinical and volumetric case series

Abstract

Introduction: Challenging implant esthetic complications are often characterized by implant malpositioning and interproximal attachment loss of the adjacent teeth. However, limited evidence is available on the treatment of these conditions. The aim of this study was to evaluate the clinical, volumetric, and patient-reported outcome following treatment of peri-implant soft tissue dehiscences (PSTDs) exhibiting interproximal attachment loss on adjacent teeth, performed through vertical soft tissue augmentation with implant submersion.Methods: Ten subjects with isolated PSTD in the anterior maxilla characterized by adjacent dentition exhibiting interproximal attachment loss were consecutively enrolled and treated with horizontal and vertical soft tissue augmentation, involving crown and abutment removal, two connective tissue grafts, and submerge healing.Clinical outcomes of interest included mean PSTD coverage, mean PSTD reduction, clinical attachment level (CAL) gain at the implant and adjacent sites and soft tissue phenotype modifications at 1 year. Optical scanning was used for assessing volumetric changes. Professional assessment of esthetic outcomes was performed using the Implant Dehiscence coverage Esthetic Score (IDES), while patient-reported esthetic assessment involved a 0-10 visual analogue scale. Results:The mean PSTD depth reduction and mean PSTD coverage at 1 year were 2.25 mm, and 85.14%, respectively. A mean keratinized tissue width (KTW) gain of 1.15 mm was observed, while the mean gain in mucosal thickness (MT) was 1.58 mm.

A decision‐making tree for evaluating an esthetically compromised single dental implant

“…15 A critical factor in determining the appropriate clinical decision is based on the presence of interproximal soft tissue with adequate thickness (≥2 mm), height (>3 mm), and width (>2 mm), to provide an adequate vascular bed to supply the connective tissue graft and provide the support needed to coronally advance the flap. 3,14,16,22 As observed in the first clinical case, presence of thin, delicate interproximal papillae necessitates replacement of the crown with one of narrower dimensions to facilitate presurgical coronal growth of the interproximal tissue. However, in the presence of mid-facial recession with or without deficient interdental papilla, temporary implant submergence is also a viable treatment modality, as it creates an environment more amenable to augment soft tissue horizontally and vertically with a connective tissue graft, without tension, during primary closure, and to potentially restore lost papilla.…”

“…14,15,23,24 Furthermore, the utility of implant submergence is dependent upon the depth and degree of buccal placement and the need for vertical augmentation. 22 Tarnow et al emphasized the need for a presence of palatal tissue at an adequate height, providing evidence of the importance of the supracrestal tissue attachment in relation to the apico-coronal location of the implant. In many cases, if the implant platform is not at least 3 mm apical from the height of soft tissue, complete closure over the cover screw may not be obtained and implant submergence may not be a useful tool in these instances to provide an adequate bed for a future soft tissue graft.…”

“…27 Unlike the tooth, the wound healing environment around a dental implant is highly avascular and devoid of living periodontal ligament cells that would normally provide a regenerative potential during early stages of wound healing. 11,22 Indeed, autogenous connective tissue grafting is still the gold standard in terms of coverage of recession defects, gaining clinical attachment, and improving the phenotype of the keratinized mucosa. [31][32][33][34][35] CTG obtained from the superficial palate, or the maxillary tuberosity, may be preferred due to its higher lamina propria content and density, along with minimal presence of fatty and glandular tissue.…”

“…[31][32][33][34][35] CTG obtained from the superficial palate, or the maxillary tuberosity, may be preferred due to its higher lamina propria content and density, along with minimal presence of fatty and glandular tissue. 22 Acellular dermal matrices may also be indicated when encountering a patient's resistance to necessitating a secondary surgical site or when autogenous harvesting may not yield enough tissue, such as in situations of generalized recession type defects. [35][36][37]…”

“…Hence, the modifications for vertical and horizontal soft tissue augmentation with CAF was proposed using a CTG on the crest of healed edentulous spaces as a platform to support the graft 15 . A critical factor in determining the appropriate clinical decision is based on the presence of interproximal soft tissue with adequate thickness (≥2 mm), height (>3 mm), and width (>2 mm), to provide an adequate vascular bed to supply the connective tissue graft and provide the support needed to coronally advance the flap 3,14,16,22 . As observed in the first clinical case, presence of thin, delicate interproximal papillae necessitates replacement of the crown with one of narrower dimensions to facilitate pre‐surgical coronal growth of the interproximal tissue.…”