Soft Tissue Management Before Surgical Placement of Implants

Tissue regeneration, whether hard or soft, can be addressed before starting the surgi- cal phase of implant placement. Having a long-standing edentulous area may lead to deficiencies of hard and soft tissues, with both affecting each other. Regeneration of one type can be influenced by the adequate presence of the other. Surgical proce- dures will lead to the formation of scar tissues, which may complicate soft tissue handling for future surgeries [35]. Scar tissues manifest less elasticity than mucosal tissues. Elasticity is required to achieve primary closure for GBR, especially verti- cal augmentation for complete coverage for the grafted bone. Incorporating more than one surgical procedure will decrease the frequency of surgeries and scar tissue formation. In case soft tissue correction is required, dental practitioners may imple- ment different techniques to increase the zone of attached gingiva before starting implant placement.

Free Gingival Graft
First described by Sullivan and Atkins (1968) [36], the free gingival graft is consid- ered one of the most common procedures utilized to increase the width and thick- ness of keratinized mucosa around natural teeth and dental implants. FGG is utilized to prevent or manage keratinized gingiva inadequacy. Careful pre-surgical evalua- tion is essential due to the limitation of the amount that can be harvested from the donor site [37]. As Harvey in 1970 recommended, it takes the recipient site approxi- mately 6 months before undergoing another surgical procedure [38]. Postoperative pain [39] and bleeding are considered common disadvantages of the FGG proce- dure. Despite the well-known disadvantages, FGG is still considered the gold stan- dard for soft tissue augmentation. Because of the known disadvantages, soft tissue substitutes were introduced and utilized to replace FGG. Even though they offer less postoperative pain and discomfort and solve the problem of limited autogenous tis- sue supply, the outcome is still inferior to that of FGG. Shrinkage and inconsistent quality of the generated soft tissues are considered major limitations, which may limit the implementation of FGG substitutes [40]. Furthermore, acellular dermal matrix (ADM) may result in regenerated tissues resembling scar tissues [41].

Before Teeth Extraction
As mentioned earlier, long-standing edematous areas may result in both hard and soft tissue insufficiency. The following case describes a female patient using a removable partial denture supported on the hopeless remaining mandibular anterior dentition. The patient is interested in having an implant-supported complete den- ture. Clinical and radiographic evaluation shows severe loss of both hard and soft tissues. FGG was indicated to increase the amount of keratinized gingival tissues and allow for primary closure during vertical bone augmentation. Hard and soft tis- sue augmentation will provide enough support for the dental implants. To minimize the needed surgical procedures and necessary time required to complete the case, combining more than one surgery in the same setting is recommended if possible.

 
To achieve the goals in this case, a free soft tissue graft was performed during the extraction procedure, as shown in Figs. 4.1, 4.2, 4.3, and 4.4.

After Teeth Extraction
A completely edentulous patient has a treatment plan to have implant-supported complete dentures. The success of implants is questionable due to a significant lack of hard and soft tissues. Soft tissue augmentation may take place first, as shown in Figs. 4.5 and 4.6. Once completed, soft tissue augmentation will be followed by hard tissue regeneration before considering implant placement, as shown in Figs. 4.7, 4.8, and 4.9.