To be more precise:
In the case of a single implant placement in anterior maxilla, what are the differences if soft tissue augmentation (for buccal profile) is performed at the time of tooth extraction, at the time of implant placement or at the time of abutment surgery?
Hi dear laura
hope my comment be useful to you
in case delayed implant placement it has been stated that the best time for soft tissue augmentation
In case of delayed implantation it has been recommended that second stage surgery is the best time for soft tissue augmentation.However when immediate implantation is planned in anterior maxilla ,the periodontal biotype of the patient should be considered.in case of thin biotype placing a connective tissue graft underneath the buccal flap is highly recomended to prevent soft tissue recession.however be carefull regarding this approach because it is a complicated procedure regarding aesthetic outcoms.The main adventage of connective tissue placement is the marginal soft tissue stability and suitable aesthetic outcome.
Quote from Speaker in IAP 2014
"Pick your periodontal probe before picking up BP Blade
In my opinion the soft tissue profile will be most stable if managed at the time of abutment profiling. Assuming that there is adequate coverage buccally, and the fixture is at least 2mm below the gingival level, there is scope to improve the aesthetic profile by bulking out and modifying the temporary abutment. There are then several recognised methods for transferring your customised abutment dimensions to the lab for a definitive restoration to be made.
I hope this helps!
A most interesting argument and collection of replies. The real question that needs to be posed is: The maxillary anterior dental region demands that any restoration meets not only the demands of function but above all aesthetics. Therefore, are practitioners experienced enough with soft tissue peri-implant surgery to be sure of achieving such goals?
Tooth extraction followed immediately by dental implant placement into a modified site shortens treatment times; this being the Type 1 Implant surgery.However, a determining factor to the aesthetic success of immediate dental implant placement will be the known resorption of the facial/labial bone post-extraction. Following Type 1 implant placement, there are early changes in the gingival soft tissues, especially in the anterior maxilla. The indications are that extraction, followed by immediate dental implant placement and socket grafting will result in soft tissue stability. Such socket grafting including both hard and soft tissue.
Confounding factors to Type 1 surgery are buccal bone dehiscence, fenestration and fractures of the buccal wall of the socket following tooth extraction - all will often negate the Type 1 implant surgery, since any 'extra' inflammatory process substantially compromises healing at the extraction site.These circumstances will often postpone the implant surgery, to what is referred to as early or delayed implant placement. However, experience has shown that such hard tissue problems do not actually compromise implant placement providing high Initial Implant Stability has been achieved.
Patients with gingival phenotype A have high risk of suboptimal aesthetic results following conventional single implant surgery: mid-facial recession being reported as a sequel to immediate implant placement and implant placement in the delayed scenario. Further, phenotype A has ‘thin’ bone that resorbs easily even if the buccal wall of a socket is patent after extraction. These findings produce the ‘high risk’ patient for maxillary anterior dental implant replacement therapy.
The autogenous subepithelial connective tissue graft that includes the underlying periosteum has factors that contribute to tissue stability, regeneration/repair and phenotype change at the recipient site.
The subepithelial connective graft is now integral to implant dentistry, being used to mask inadequate alveolar soft tissue volume and suboptimal aesthetic morphology at peri-implant sites.The subepithelial connective tissue graft (SCTG) is frequently used at periodontal recession sites to increase the volume of soft tissue at a deficient site and also convert ‘thin’ periodontal phenotype A into a stable ‘thick’ gingival phenotype B. 'Thick' gingival biotype resists recession and helps maintain gingival morphology. Further, inherent thick tissue biotype is important because thick tissues have an increased blood supply that will enhance neo-vascularisation of bone grafts leading to increased rate of healing and graft incorporation.
Further, the SCTG incorporating the donor periosteum has other attributes: Pericytes, which will facilitate angiogenesis and neovascularization at the implant site during immediate implant placement.
If the surgeon chooses not to use these SCTG attributes in the extraction/immediate implant placement, but waits until abutment placement, he/she has lost these inherent characteristics which would have contributed to the initial wound healing, tissue stabilization, hard tissue and soft tissue graft incorporation.
In conclusion, preferentially, SCTG incorporating the underling periosteum from the donor site should be carried out at the time of implant surgery whether it is in the extraction/immediate placement scenario or in the delayed scenario. The waiting until abutment placement is totally illogical - one forgoes the attributes of the SCTG. However, its use is determined heavily by experience and high skill levels.
I hope this is of use to everyone. The attachment may be of assistance to many.
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