Soft tissue management for Implant site development 2003

Soft tissue management for Implant site development 2003년 5월 6일 치주과 박정주 KHU Perio

목차 1. Prologue 2. Soft tissue management around implant 1) Primary closure 2) Increasing keratinized mucosa 3) Soft tissue augmentation 4) Soft tissue sculpting 3. Implant 2 nd surgery 4. Techniques KHU Perio

Implant주위의 tissue management시기 1 Five phase (Jovanovic, 1997) 1. First phase Prior to implant Ridge deficiency has more than 3 mm in vertical bone loss and a width of less than 3 mm 2. Second phase Simultaneous implant Moderate bone loss of up to 3 mm vertically and width of 3 mm to 5 mm KHU Perio

3. Third phase During healing phase of implant 4. Fourth phase Surgical exposure of implant 5. Fifth phase Healing period following exposure of implant Soft tissue guided by divergent abutment or provisional restoration KHU Perio

Soft tissue augmentation은 5개의 phase에 다 이용될수 있다. KHU Perio

Soft tissue management around Implant 1. Primary closure 2. Increasing of keratinized mucosa 3. Soft tissue augmentation horizontal/vertical 4. Soft tissue sculpting KHU Perio

Primary closure KHU Perio

연조직의 초기 폐쇄(primary closure)방법 3 1. 2. 3. 4. 5. KHU Coronally repositioned flap Rotated buccal pediculated flap Rotated split palatal flap Free connective tissue graft Free autogenous gingival graft Perio

Increasing of keratinized tissue KHU Perio

Classification of Attached Gingiva ( Ono et al. 1998) KHU Perio

Classification of Attached Gingiva KHU Perio

Classification of Attached Gingiva KHU Perio

Classification of Attached Gingiva KHU Perio

Keratinized tissue증가 방법 1. 2. 3. 4. KHU Apically positioned flap Free gingival graft Connective tissue graft Split palatal flap Perio

Soft tissue augmentation KHU Perio

Soft tissue augmentation 2 1. Horizontal augmentation pediculated flap(roll technique), connective tissue graft, interpositional graft, barrier membrane w/ bone graft (GTR) 2. Vertical augmentation GSTA , GSTA w/ CTG, onlay graft KHU Perio

Developing the gingival profile KHU 1. Sufficient hard tissue must be present to support 4 mm of soft tissue(biologic width) (saadoun, 1999)4 2. The keys to predictable esthetic success in single implant replacement must be ideal site development and proper implant positioning(Priest, 2003)5 3. Soft tissue form around single implant is more influenced by surrounding osseous level than by crown contours ( Saadoun, 1999) Perio

Developing the gingival profile 1. Overcontour the soft tissue recession: Implant exposure후 6개월에 1 mm (Tarnow, 2000), 처음 3개월동안 심하 고 1년까지 평균 1 mm 2 -3 mm addition to compensate for future recession (Bengazi, 1996) 20% overcontour(Tarnow, 2000) 2. Guide line an imaginary line drawn from the papillary height to the papillaray height of the proximal teeth KHU Perio

Soft tissue sculpting 2, 21 • Provisional restoration에 의한 custom guided tissue healing (restoration-generated site development) 1. provional restoration을 이용하여 soft tissue sculpting과 적절한 emergency profile을 확립한다. 2. 인접면에서는 치은연하의 contour를 over로 하면 치 간부 연조직이 치관방향으로 이동해 치간유두조직이 형성된다. 순협측부위의 emergence profile을 가능한 한 flat하게 하여 순협측 연조직이 퇴축되지 않도록 한 다. 3. provisional 장착초기에는 30% 줄여서 하고 2주일후 변연조직이 순응해오면 인접치와 조화를 이루게 한다. (Paul&Jovanovic, 1999)21 KHU Perio

2 nd surgery Implant exposure KHU Perio

*임플란트 2차수술시 연조직증대및 치간유두 재건 1. Pedicle flap Roll technique, double layer flap 2. Connective tissue graft pouch, inlay 3. Palacci technique 4. Nemcovsky technique 5. PK flap 6. Rotated Split palatal flap 7. Palatal sliding strip flap 8. Coronally positioned palatal sliding flap 9. GSTA(guided soft tissue augmentation KHU Perio

방법의 선택 6 *Protocol for maintaing or increasing the width of masticatory mucosa (Barone, 1998) Distance between the emergence of the implant from bone and MGS 3 mm or less: Apically positioned flap 3 mm이상: Gingivectomy KHU Perio

Apically positioned flap Gingivectomy KHU Perio

Soft tissue management techniques KHU Perio

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Guided Soft Tissue Augmentation(GSTA)9 (Salama, 1998) 1. submerged healing abutment to optimize the tree-dimensional enhancement of the peri-implant soft tissue profile 2. “Dead space” is created during 2 nd surgery by tenting the repositioned flap over healing abutments of appropriate height 3. 6 -8주후 exposure 4. 1 st , 2 nd surgery시에 이용 KHU Perio

Palacci technique 10 2 nd surgery Reliable method in posterior implants KHU Perio

Nemcovsky et al. (2000)11 2 nd surgery 1. The U-shaped incision adjacent papilla 2. The outer edges of the incision and approximal papillae are de-epithelialized 3. A full thickness flap is raised KHU Perio

Nemcovsky et al. (2000) 4. The flap is split in its center, separating it in mesial and distal parts 5. This incision is extended to the desired location of the buccal gingival margin of the future restoration 6. Suture KHU Perio

PK flap 10 KHU (Park & Kim’s) 2 nd surgery에 이용 Multiple Z plasty의 변형 Labial에 형성된 papilla들을 palatal에서 Perio supporting

Palatal Sliding Strip Flap 12 (Adriaessens et al. 1999) 2 nd surgery에 이용 Papilla 형성과 buccal augmentation 1. Full-thickness sulcular and palatal displaced incision 2. A two-thirds of the distance between the 2 teeth, a fullthickness horizontal incision is prolonged on the palatal side 3. Two incisions are made to create a partial-thickness flap extending in the palate KHU Perio

Palatal Sliding Strip Flap 4. The healing abutment is inserted 5. A semilunar incision is made in the direction of the contralateral side of the strip 6. provides 2 pedicles The pedicles are disengaged and rotated toward the palatal direction to fill the interproximal space 7. Simple sutures, with no tension, are made KHU Perio

Rotated Split palatal flap (Nemcovsky, 1999) # 이용 Prior to implant 13 Immediate implant 14 Implant uncovering 15 # 장점 1. 골막이 치주부착증진의 장벽의 역할 2. MGJ변화 없다. 3. 각화 조직이 증가 4. 구개에 2차적인 surgical wound가 없다. KHU Perio

Rotated Split Palatal Flap 1. Crestal incision palatal to the implants. Mesial and distal V-shaped releasing incisions 2. Full-thickness mucoperiosteal flaps 3. Palatal flap is split into 2 layers: deep and superficial. The deeper flap transforms into a pediculated one KHU Perio

Rotated Split Palatal Flap 4. Small, curved incisions are made in buccal flap facing healing abutments to improve flap adaptation 5. Buccal flap is closely adapted to the healing abutment 6. Deep split palatal flap is sutured and superficial flap is sutured KHU Perio

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Modified Roll Technique (Scharf et al, 1992 ) 2 nd surgery에 이용 1. A shallow incision on palatal to the crest 2. Parallel vertical full thickness incisions on the palate 3. The epithelial pedicles is reflected toward the palate 4. The connective tissue pedicle reflected from the palate 5. The connective tissue pedicle is rolled to the buccal aspect, between the periosteum and the bone KHU Perio

Beveled palatal approch 17 (Shapira, 2002) 1. Modified roll technique 2. Pedicle graft is composed of palatal CT under palatal trap door and the deepithelized crestal tissue overlying implant KHU Perio

Double-layer flap 18 KHU (Landi, 2001) 1. Double layer flap형성 2. Inner full thickness layer is repositioned for recipient bed 3. The outer partial thickness flap is apically sutured to deepen vestibule 4. FGG이용가능 Perio

Double-layer flap #이용 1. Remove barrier membrane 2. Exposure the implant(2 nd surgery) #장점 1. Protect interproximal bone 2. Deepen the vestibule 3. Increase keratinized tissue KHU Perio

Strip Gingival Autograft (Han & Takei, 1995) 2 mm wide and 0. 5 - 0. 75 mm thickness Minimal trauma KHU Less bleeding and discomfort Perio

Inlay-Graft Technique 19 (Grunder, 1997) 1. In case the keratinized gingiva is moved from the palatal aspect to the buccal side 2. The graft shoud be slightly thicker than the mucosa 3. The concave soft tissue is sculpted for the desired form of ovate pontic KHU Perio

Soft tissue expansion 20 (Zeiter, Sanders, 1998) 1. Implant 식립전에 GBR시 graft coverage를 위한 연조직 증대를 위해 soft tissue expander를 사용 2. STE-Xemax surgical products or “baloon” : saline-fillable silicone tube with a self-sealing port KHU Perio