Esthetic Grafting for Small Volume Hardand Soft Tissue Contour Defects for

Implant Site DevelopmentBach Le, DDS, MD,* and Jeffrey Burstein, DDS, MD†

One of the keys to creating anesthetic illusion of a naturaltooth is to execute an ideal

emergence profile.1 A critical part ofthe emergence profile is based on thetype of tissue surrounding the toothand whether any defects in the under-lying bone are present. Although dif-ferent opinions exist as to whether alack of an attached portion of masti-catory mucosa may jeopardize themaintenance of the soft tissue healtharound dental implants,2,3 there aremany procedures available to increasethe thickness of this tissue. These pro-cedures include inlay grafts4 and onlaygrafts5 which involve harvesting tissuefrom a new patient donor site6 or usingacellular dermal matrix grafts like Allo-derm (LifeCell Corporation, Branch-burg, NJ).7,8 Other options are flapmanipulation procedures9 such as thevascularized interpositional periosteal-connective tissue flap,10 and controlledtissue expansion techniques.11 Manyother flap designs have been reportedincluding the palatal roll technique, slid-ing and rotating flaps.10,12–16

Ideally the contour of the gingivaltissue on the alveolar ridge is devel-oped before implant placement.1,17–19

If needed, soft tissue augmentation toimprove the gingival contours can oc-cur at implant placement20,21 and, ifneeded, at the implant uncovery stageor even later.1,17,22 When bony defectsexist before implant placement and

the implant is placed and restoredwithout consideration for these de-fects, the result can be an unnaturalappearance (Fig. 1). Soft tissue graft-ing can be advantageous in situationswhere there is a thin biotype, metaldisplay of the implant collar or as amore predictable method for smallvertical augmentation of the soft tis-sue. However, the majority of smallsoft tissue deficiencies are representedby an underlying bony defect. Primar-ily soft tissue grafting to treat thesepatients has many limitations includ-ing increased postoperative sequelae,surgical time, and increased expensewith a second surgical site.

Although large volume defects, asseen in a severely atrophic maxilla, areconceptually 1-wall defects (ie, knifeedge ridge) which require the use oftitanium mesh or cortical tentpolegrafting techniques,12 the small volumeperi-implant bony defects can be com-pared with a 3-wall defect which can becorrected with a simple technique usingparticulate mineralized allograft. The re-sult is the augmentation of small hardand soft tissue labial defects resulting inthe functional and cosmetic results de-sired. Block demonstrated that aug-menting the deficient alveolus can besuccessfully performed using a tunnel-

ing technique23 to place particulatemineralized allograft in the posteriormandibular ridge. We successfullyused this technique to augment themandibular ridge with excellent re-sults and core biopsies taken from theaugmented sites 5 months after place-ment of the graft revealed adequateviable bone. However, the disadvan-tage of the tunneling technique is thatit is difficult to position the graft coro-nally into an esthetic position to aug-ment the labial concavity. To avoidthe difficulty of placing the graft ex-actly where it is needed, lateral aug-mentation of the alveolar processshould be done under direct vision toachieve excellent results.24 We haveexpanded on this concept to treat smallhard and soft tissue defects. By usingthis technique it is possible to createan esthetic result where the coronalsoft tissue is supported by bone and, inthe majority of cases, this eliminatesthe need for a subepithelial connectivetissue graft. This, in essence, treats theproblem at its underlying origin.

SURGICAL TECHNIQUE

This simple procedure to augmentsmall soft and hard tissue defects with-out taking a connective tissue graft

*Assistant Professor, Department of Oral and MaxillofacialSurgery, USC School of Dentistry, Los Angeles, CA.†Chief Resident, Department of Oral and Maxillofacial Surgery,USC School of Dentistry, Los Angeles, CA.

ISSN 1056-6163/08/01702-136Implant DentistryVolume 17 • Number 2Copyright © 2008 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e318174db99

Ridge contour defects arounddental implants are caused by under-lying bony defects. Although adequatebone may exist to obtain stability ofthe implant, irregular bony anatomycan result in an unnatural appear-ance of the final crown. Particulateonlay grafting to support the peri-implant soft tissue along with

tension-free closure while usingpedicle papilla regeneration tech-niques can convert unaesthetic gin-gival contours into favorable sites.(Implant Dent 2008;17:136–141)Key Words: dental implants, onlaygrafting, papilla regeneration

136 ESTHETIC GRAFTING FOR IMPLANT SITE DEVELOPMENT

involves direct exposure of the labialdefect at any stage of implant place-ment. In Figure 2, A we demonstratethe use of this procedure coincidentwith implant placement. The tech-nique involves a crestal incision,slightly palatal to the midline, with afull-thickness subperiosteal pouch tothe labial of the implant with a smalldistal vertical release if needed. Thehuman mineralized allograft bone (Pu-ros; Zimmer Dental, Carlsbad, CA), isthen placed against the labial bone sur-face with sufficient volume to correctany contour defect. Resorption andapical migration of the graft materialis expected, so it is important to over-correct the defect by 30%. The pa-tients own blood is used as a coagulant

for better cohesiveness and handlingof the graft material. If there is ade-quate primary stability of the implant,then a single stage protocol is pre-ferred. Before placing the bone it iscritical to release and advance theperi-implant soft tissue by scoring theperiosteum so that tension-free closurecan be obtained around the healingabutment. For a better esthetic result, alarge diameter healing abutment ispreferred as it acts as a tenting mecha-nism to support the graft and peri-implant soft tissue. Moderate resorptionof graft material can be expected ifthere is not an adequate tissue sealaround the healing abutment and iftension-free closure is not achieved. Avariation of Palacci’s25 papilla regener-ation technique (Fig. 2, B) helps to aug-ment the interdental height and softtissue papillary volume when an ade-quate zone of peri-implant keratinizedtissue is present (Fig. 2, C).

Two cases (Figs. 3 and 4) inwhich the labial contour defect iscorrected with particulate bone areshown. In Figure 3, mineralized par-ticulate allograft was used in theesthetic zone under direct vision to aug-ment a contour defect. In supportingboth of these defects with bone ratherthan grafting additional soft tissue tothe region, we ensure the bony supportto maintain the esthetic contour. Inaddition, we avoid the additional pain-ful donor site incision to the palate.

DISCUSSION

After tooth extraction, socket re-modeling can result in loss of up to 40%to 60% of the alveolar ridge widthwithin the first 1 to 2 years.26 Labialridge deformity can be more severe ifthere is damage to the buccal plate dur-ing tooth removal. Atwood and Coy27

performed clinical and densitometrystudies on residual ridges after tooth lossand found that bone resorption activitycontinues throughout life. As a result, itis anticipated that many patients withtooth loss will have varying degrees ofalveolar ridge resorption. This resorp-tion can lead to compromise in the po-sition of the implant fixture. Even whenthere is adequate bone to place implants,irregular ridge contours can result in anunnatural appearance of the final crown(Fig. 1, A).

In addition, the importance ofhaving adequate labial bone thick-ness around implants cannot be un-derestimated. Most mucogingivaldeficiencies which occur arounddental implants result from loss ofunderlying bone attachment to thefixture. Spray et al28 confirmed theneed for adequate facial bone thick-ness after implant placement to min-imize labial bone height loss. Theydetermined the ideal facial thicknessto be 2 mm. When there was lessthan 2 mm, vertical bone loss oc-curred at a greater frequency.

The rationale for use of particulatemineralized allograft to reconstructsmall contour defects is to give sup-port to the overlying soft tissue to cre-ate a more natural appearance. Inaddition to improving esthetics, theadditional bone thickness providesstability in maintaining labial boneheight. The feasibility of using partic-ulate mineralized allograft in a closedtunneling fashion was successfullydemonstrated by Block and Degen.23

Le et al29 used particulate mineralizedallograft in an open onlay technique tosuccessfully augment 10 consecutivepatients with severely atrophic maxil-lary ridges for implant placement. Thebone quality achieved in their patientpopulation was sufficient for success-ful integration of 41 of 42 implants.These reports show that mineralizedallograft can be successful in aug-menting atrophic alveolar ridges forimplant placement.

The advantage of using an opengrafting technique is that it can beperformed at the time of implantplacement, in a single-stage implantplacement protocol. The single-stageprotocol minimizes compression andmigration of particulate graft mate-rial and it allows the bony and softtissue architecture to develop aroundthe healing abutment during thehealing phase. A large diameter heal-ing abutment, in a single-stage place-ment protocol, provides tenting of theperi-implant soft tissue and results inless apical migration of graft material.This improves the prognosis of safe-guarding the width and height of theremaining crestal bone. Grafting at thetime of implant placement also takesadvantage of the regional acceleratoryphenomenon30 that is induced by the

Fig. 1. Implant-supported crown shows un-natural ridge contour.

Fig. 2. A, Particulate allograft augmentationof contour defect and release of periosteumto obtain tension-free closure. B, Rotation ofpedicled flaps to adapt gingival tissues to im-plant healing abutment and to augment pap-illary tissue volume.

IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 137

trauma of implant placement, leadingto a reduced healing time.

Some authors4,5,8,10–13 advocate theuse of connective tissue grafts or acel-lular dermal matrix grafts for treat-ment of small volume contour defects.Although good results can be achievedin minor defects, the connective graftis merely replacing missing bone bymasking it with soft tissue volume.

Particulate bone graft may be a betteralternative because it treats the under-lying bone problem to restore the nat-ural support of the tissue architecture.Oftentimes, this negates the need foradditional tissue grafting. In addition,the use of readily available allograftmaterial negates the obvious disadvan-tages of having to harvest autogenousbone or connective tissue. This de-

creases the morbidity, expense andtime of the implant procedure.

CONCLUSION

Particulate onlay grafts can beused to convert unhealthy and unaes-thetic gingival contours into favorablesites. In reviewing the various tech-niques used to develop the implant siteat the buccal aspect of the ridge, 1simple technique was demonstrated toimprove the peri-implant esthetics atdifferent stages of implant placement.Correction of labial defects is just oneof the many factors leading to excel-lent esthetic results. Just as importantare treatment planning and case selec-tion, correct implant placement,proper abutment selection and estheticfabrication of the final crown.17 Theresults shown are at 2 years after graft-ing. A longer follow-up is needed toevaluate the long-term stability ofthese grafting techniques described.

Disclosure

The authors claim to have no finan-cial interest, directly or indirectly, in anyentity that is commercially related to theproducts mentioned in this article.

ACKNOWLEDGMENTS

The authors acknowledge Steve Cook,graphic designer, for his help in artisti-cally depicting our grafting techniques.

REFERENCES

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2. Wennstrom JL, Bengazi F, LekholmU. The influence of the masticatory mu-cosa on the peri-implant soft tissue condi-tion. Clin Oral Impl Res. 1994;5:1-8.

3. Artzi Z, Tal H, Moses O, et al. Mucosalconsiderations for osseointegrated implants.J Prosthet Dent. 1993;70:427-432.

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5. Seibert J. Reconstruction of de-formed partially edentulous ridges, usingfull thickness onlay grafts. Compend Con-tin Educ Dent. 1983;4:437-453.

6. Sullivan HC, Atkins JH. Free autog-enous gingival grafts. 3. Utilization of graftsin the treatment of gingival recession. Pe-riodontics. 1968;6:152-160.

Fig. 3. A, Preoperative view of tooth 7 with labial bone defect. B, Sculpting ridge with partic-ulate graft to correct contour defect. Note overcorrection of defect with graft material inanticipation of some resorption. C, D, 2 years follow-up final restoration.

Fig. 4. A, Preoperative contour defect of tooth 3. Incision made slightly palatal to midline to capturean adequate band of keratinized tissue around the future restoration. B, Buccal contour defectovercorrected with particulate bone. C, Four months after single-stage placement showing excel-lent improvement in buccal contour. D, E, One year follow-up final restoration.

138 ESTHETIC GRAFTING FOR IMPLANT SITE DEVELOPMENT

7. Harris RJ. A comparative study of rootcoverage obtained with an acellular dermalmatrix versus a connective tissue graft: Re-sults of 107 recession defects in 50 consec-utively treated patients. Int J PeriodonticsRestorative Dent. 2000;20:51-59.

8. Cummings LC, Kaldahl WB, AllenEP. Histologic evaluation of autogenousconnective tissue and acellular dermal ma-trix grafts in humans. J Periodontol. 2005;76:178-186.

9. Nemcovsky CE, Moses O. Rotatedpalatal flap. A surgical approach to in-crease keratinized tissue width in Maxillaryimplant uncovering: Technique and clinicalevaluation. Int J Periodontics RestorativeDent. 2002;22:607-612.

10. Sclar A. Soft Tissue and EstheticConsiderations in Implant Therapy. Surrey,UK: Quintessence Publishing; 2003;163-187.

11. Bahat O. Interrelations of soft andhard tissues for osseointegrated implants.Compend Contin Educ Dent. 1996;17:1161-1170.

12. Minsk L. The use of acellular der-mal connective-tissue graft for root cov-erage in periodontal plastic surgery.Compend Contin Educ Dent. 2004;25:170-176.

13. Wennstrom JL. Mucogingival ther-apy. Ann Periodontol. 1996;1:671-701.

14. de Trey E, Bernimoulin JP. Influ-ence of free gingival grafts on the health ofthe marginal gingiva. J Clin Periodontol.1980;7:381-393.

15. Goodacre CJ. Gingival esthetics.J Prosthet Dent. 1990;64:1-12.

16. Karlsen K. Gingival reactions todental restorations. Acta Odontol Scand.1970;28:895-904.

17. Garber DA, Belser UC. Restorative-driven implant placement with restoration-generated site development. CompendContin Educ Dent. 1995;1:796-804.

18. Phillips K, Kois JC. Aesthetic peri-implant site development. The restorative con-nection. Dent Clin North Am. 1998;42:57-70.

19. Misch CE. Contemporary ImplantDentistry. 2nd ed. St. Louis, MO: CVMosby; 1999;393-394.

20. Tarnow DP, Eskow RN. Consider-ations for single-unit esthetic implant res-torations. Compend Contin Educ Dent.1995;16:778-788.

21. Shaban M. Soft tissue closure overimmediate implants: Classification and re-view of surgical techniques. Implant Dent.2004;13:33-41.

22. Simion M, Misitano U, Gionso L,et al. Treatment of dehiscences and fenes-tration around dental implants using resorb-able and nonresorbable membranes associ-ated with bone autografts: A comparativeclinical study. Int J Oral Maxillofac Implants.1997;12:159-167.

23. Block MS, Degen M. Horizontal ridgeaugmentation using human mineralized partic-ulate bone: Preliminary results. J Oral Maxillo-fac Surg. 2004;62(9 suppl 2):67-72.

24. Hellem S, Astrand P, Stenstrom B,et al. Implant treatment in combination withlateral augmentation of the alveolarprocess: A 3-year prospective study. ClinImplant Dent Relat Res. 2003;5:233-246.

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Reprint requests and correspondence to:Bach Le, DDS, MDDepartment of Oral and Maxillofacial SurgeryUSC School of Dentistry/LA County MedicalCenterOPD 1P51, 2010 Zonal AvenueLos Angeles, CA 90089Phone: (323) 226-5013Fax: 323-226-5241E-mail: burstein@usc.edu orleb97201@yahoo.com

Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Bach Le, DDS, MD, Jeffrey Burstein, DDS, MD.Korrespondenz an: Bach Le, DDS, MD, Gesichts- und Kiefer-chirurgie (Oral & Maxillofacial Surgery), USC zahnmediz-inische Fakultat/medizinisches Zentrum des Stadtbezirks LA(USC School of Dentistry/LA County Medical Center), OPD1P51, 2010 Zonal Avenue, Los Angeles, CA 90089. Telefon:(323) 226-5013, Fax: 323-226-5241. eMail: burstein@usc.edubzw. leb97201@yahoo.comAsthetischer Transplantationsansatz fur kleinere Defekte in Hart-und Weichgewebe zum Aufbau einer Implantierungsoption

ZUSAMMENFASSUNG: Defekte in der Leistenkontur imBereich um Implantate herum werden durch diesen zuGrunde liegende Knochendefekte hervorgerufen. Obwohleventuell entsprechendes Knochengewebe zur Stabilisierungdes Implantats vorhanden sein kann, kann eine von der Normabweichende Kochenanatomie dennoch zu einem unnaturli-chen Erscheinungsbild der abschließenden Uberkronung fu-

hren. Eine Partikel-Onlay-Spanung zur Unterstutzung des dasImplantat umgebenden Gewebes in Verbindung mit Span-nungsfreiem Verschluss bei Verwendung von Techniken zurRegeneration der Stielpapille kann wenig asthetisch erschei-nende Zahnfleischkonturen zu gut geeigneten Implan-tierungsstellen umformen.

SCHLUSSELWORTER: Zahnimplantate, Onlay-Spanung,Papillenregeneration

SPANISH / ESPAÑOLAUTOR(ES): Bach Le, DDS, MD, Jeffrey Burstein, DDS,MD. Correspondencia a: Bach Le, DDS, MD, Oral &Maxillofacial Surgery, USC School of Dentistry/LACounty Medical Center, OPD 1P51, 2010 Zonal Avenue,Los Angeles, CA 90089. Telefono: (323) 226-5013, Fax:323-226-5241, Correo electronico: burstein@usc.edu oleb97201@yahoo.com

IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 139

Injerto estetico en defectos de tejido duro y blando de pequenovolumen para el desarrollo de lugares de implante

ABSTRACTO: Los defectos del contorno de la cresta alrededorde los implantes dentales son causados por defectos oseossubyacentes. A pesar de que podrıa existir un hueso adecuadopara obtener la estabilidad del implante, una anatomıa irregulardel hueso puede resultar en una apariencia innatural de la coronafinal. El injerto incrustado de partıculas para apoyar el tejidoblando periimplante con un cierre sin tension mientras se utilizantecnicas de regeneracion de la papila pedicular puede convertirlos contornos gingivales poco esteticos en lugares favorables.

PALABRAS CLAVES: Implantes dentales, injertos incrusta-dos, regeneracion de la papila

PORTUGUESE / PORTUGUÊSAUTOR(ES): Bach Le Cirurgiao-Dentista, Medico, JeffreyBurstein Cirurgiao-Dentista, Medico. Correspondenciapara: Bach Le, DDS, MD, Oral & Maxillofacial Surgery,USC School of Dentistry/LA County Medical Center, OPD1P51, 2010 Zonal Avenue, Los Angeles, CA 90089. Tele-fone: (323) 226-5013, Fax: 323-226-5241, E-mail:burstein@usc.edu ou leb97201@yahoo.comEnxerto Estetico para Defeitos de Tecido Duro e Mole dePequeno Volume para Desenvolvimento de Local de Implante

RESUMO: Os defeitos do contorno do rebordo em torno deimplantes dentarios sao causados por defeitos osseos subja-centes. Embora o osso adequado possa existir para obter aestabilidade do implante, a anatomia ossea irregular poderesultar numa aparencia nao-natural da coroa final. O enxertoparticulado onlay para apoiar o tecido mole do periim-plante, junto com o fechamento isento de tensao, enquantose utilizam tecnicas de regeneracao da papila do pedıculo,pode converter contornos gengivais nao-esteticos em lo-cais favoraveis.

PALAVRAS-CHAVE: Implantes dentarios, enxerto onlay,regeneracao da papila

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Dentistry/LA County Medical Center, OPD 1P51, 2010 ZonalAvenue, Los Angeles, CA 90089. ������: (323) 226–501,����: 323-226-5241, ����� ��������� ���:burstein@usc.edu � leb97201@yahoo.com����� �� ������������ ��� ������������ �� ����� � ��� �� ��� �������������� ��� �� ����� ��!� ��� �������

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TURKISH / TURKCEYAZARLAR: Di Hekimi, Dr. Bach Le, Di Hekimi, Dr.Jeffrey Burstein. Yazıma için: Bach Le, DDS, MD, Oral& Maxillofacial Surgery, USC School of Dentistry/LACounty Medical Center, OPD 1P51, 2010 Zonal Avenue,Los Angeles, CA 90089 ABD. Telefon: (323) 226-5013,Faks: 323-226-5241, Eposta: burstein@usc.edu veyaleb97201@yahoo.commplant Yerinin Gelitirilmesi için Az Hacimli Sert ve Yu-muak Doku Kusurlarının Estetik Greftlenmesi

ÖZET: Dental implantların etrafındaki kret kontur kusurları,altta yatan kemiksel kusurlardan kaynaklanır. mplantta stabilitesalayacak yeterli kemik olsa bile, eer düzensiz kemik anato-misi mevcutsa, son kron doal olmayan bir görüntü alabilir.Pedikül papilla rejenerasyon teknikleri kullanılırken, peri-implant yumuak dokuyu destekleyecek parçacıklı onlay greftyapılır ve gerilimsiz kapanı salanırsa, estetik özellii ol-mayan dieti konturları daha estetik hale getirilebilir.

ANAHTAR KELMELER: Dental implantlar, onlay greft, pa-pilla rejenerasyonu

JAPANESE /

140 ESTHETIC GRAFTING FOR IMPLANT SITE DEVELOPMENT

CHINESE /

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