Soft Tissue Management During Second Stage of Dental Implants

Soft tissue deficiencies can be corrected during the second stage of implant surgery. This section of the chapter reviews different techniques that can be utilized to address such problems. The dentist should use clinical judgment to determine which technique, classical or modified, would best match the clinical circumstances and to provide better aesthetic and/or functional outcomes

Apically Positioning Flap
An apically positioned flap is a simple modality to increase the zone of keratinized tissues around natural teeth and dental implants. This technique does not involve a second surgical site as in free gingival and connective tissue grafts. One of the limi- tations of this technique, though, is that it does not increase biotype thickness (Figs. 4.28, 4.29, and 4.30).

Free Gingival Graft
Free soft tissue graft can also be utilized to increase the zone of keratinized gingiva around dental implants. Due to the difference in color between the palatal donor site and the buccal recipient site, the esthetic outcomes may be compromised. In the following case, the author introduced a technique in which he used buccal keratin- ized gingiva as a donor site instead of the palatal site. Since harvesting tissues from the donor site can induce gingival recession around existing dentition, the dentist needs to make sure there is an abundance of tissues to harvest from without approaching the free gingival margin.

The following case is of a female patient who had immediate implant placement in the areas of tooth #5 with bone augmentation and resorbable collagen barrier (Figs. 4.31, 4.32, and 4.33). To achieve primary closure, the mucogingival junction  was coronally displaced (Fig. 4.34). During the second stage, a free gingival graft was performed to compensate for the lack of keratinized gingiva on the buccal side of the implant (Fig. 4.35). The buccal side of teeth # 2–3 was used as a downer site to harvest soft tissue graft, as shown in Figs. 4.36 and 4.37. Figure 4.38 shows the final implant-supported crown restoration.

Rotated Pedicle Flap
Since it was first published by Harvey, P.M in 1970, a pedicle flap has been imple- mented to manage and treat the lack of keratinized mucosa around dental apparatus. The next case shows how a rotated pedicle flap can be used while performing the second stage around implants to compensate for keratinized mucosa deficiency around implants (Figs. 4.39, 4.40, 4.41, 4.42, 4.43, and 4.44).


Rotated Connective Tissue Graft
As a modification to the conventional connective tissue graft, this technique can be utilized to compensate for a lack of adequate thickness of soft tissue around dental implants.

Applying the same surgical principles of soft tissue grafting, the graft should be immobilized with adequate length and thickness and have enough vascularity to provide adequate blood supply to ensure graft survival. If the graft is meant to cover a surface that has no blood supply as in denuded roots or the implant surface, the practitioner must make sure there is enough blood supply coming from the peripher- ies of the graft by harvesting an adequately sized graft to provide the needed blood supply.

A newer technique has been introduced, which is called vascularized interposi- tional periosteal connective tissue flap (VIP-CT) [50]. Figs. 4.44, 4.45, 4.46, 4.47, 4.48, and 4.49 represent a case where that technique was utilized to increase the zona of keratinized tissues around four implants placed in the area of missing teeth of the maxillary left side. The procedure was completed during the second stage after allowing adequate time for osseointegration in preparation for the restor- ative phase.