Enhancing vertical hard and soft tissue in implant dentistry
Nick Vourakis shares his approach to enhancing vertical and horizontal bone and soft tissue in implant dentistry, focusing on preventing complications and the importance of ongoing mentorship.
Over the years, I’ve seen that achieving stable, long-term outcomes in implant cases isn’t just about the implant itself; it’s about preserving, increasing, and stabilising the surrounding hard and soft tissue. In this article, I’d like to summarise the five key elements of my approach to tissue reconstruction, complication management, and patient care, which I designed to support fellow implant dentists in navigating these complex cases.
1. Understanding bone and soft tissue dynamics
When it comes to implant placement, the biological dynamics of the surrounding tissues are paramount. Tooth extraction leads to a significant reduction in bone volume, particularly in the first eight weeks. This happens because extraction disrupts the blood supply to the bundle bone, an essential part of the alveolar bone where periodontal ligaments anchor. As a result, we lose bone, especially in the buccal area, which presents both vertical and horizontal defects, particularly in patients with a thin gingival phenotype.
From my perspective, one of the key points is recognising the symbiotic relationship between bone and soft tissue. Both are essential for long-term implant stability and aesthetics. Ideally, we aim for a minimum of 2mm of bone surrounding the implant and a thick, keratinised mucosa layer, which enhances stability and supports the patient’s ability to maintain proper oral hygiene.
2. Techniques for hard and soft tissue augmentation
In my practice, achieving stable and adequate bone and soft tissue volume is foundational for any successful implant case. For soft tissue augmentation, I often turn to the de-epithelialised gingival graft technique developed by Professor Zucchelli (2010), which involves harvesting connective tissue from the patient’s palate. This technique thickens and keratinises the mucosa around the implant, minimising the risk of peri-implant diseases and supporting long-term aesthetics.
Guided bone regeneration (GBR) is my go-to method for bone augmentation, particularly for more complex cases.
Guided bone regeneration (GBR) is my go-to method for bone augmentation, particularly for more complex cases. GBR involves using barrier membranes to create an environment that supports new bone growth. I believe the four pillars of successful GBR are stability, angiogenesis, space maintenance, and tension-free primary closure. I use autogenous bone whenever possible due to its osteogenic, osteoinductive, and osteoconductive properties. However, depending on the case, I also use allografts, xenografts, and synthetic materials, especially when I need additional volume or structural support.
3. Advanced techniques: The Sausage and Khoury Plate methods
Two of my preferred techniques for advanced augmentation cases are the Sausage Technique and the Khoury Plate Method. The Sausage Technique, popularised by Dr Istvan Urban (2017), is highly effective for both horizontal and vertical augmentation. It involves securing a resorbable or non-resorbable membrane over the bone graft using pins and screws to create a ‘sausage’ effect, which stabilises the graft. I find this approach particularly beneficial when dealing with molar regions where the bone is thin.
For vertical defects, I often use the Khoury Plate Method. This technique requires harvesting a bone block from the ramus or chin, splitting it into thin plates, and securing it with titanium screws to form a scaffold. It’s an ideal method for cases with large vertical defects, although it’s a more advanced procedure that demands significant experience.
4. Managing complications: Prevention and protocol
Complications are inevitable when performing complex implant procedures. The goal, however, is to be proactive and prepared to handle them when they arise. Common issues include membrane exposure, infection, and graft failure. Setting realistic expectations and keeping the patient informed is essential in high-risk cases such as those involving vertical bone augmentation or patients with a penicillin allergy. I also implement strict aseptic protocols, which I consider essential, particularly when working in challenging environments.
Setting realistic expectations and keeping the patient informed is essential in high-risk cases such as those involving vertical bone augmentation or patients with a penicillin allergy.
Regular follow-up is critical for these advanced cases, particularly within the first six weeks. I typically see patients weekly in the initial phase to monitor healing. Early intervention can often salvage the graft and minimise the impact if complications arise. In my experience, the first six weeks are crucial, especially for maintaining the integrity of GBR membranes. If a membrane becomes exposed after six weeks, it can usually be removed with minimal graft loss.
5. Training and mentorship
I highly recommend structured training programmes and mentorship for those looking to expand their bone and tissue augmentation skills. Before attempting vertical augmentation, it is essential to start with simpler horizontal techniques using resorbable membranes and master flap design. I offer chairside visitations in collaboration with BioHorizons Camlog, where I mentor clinicians on their cases. I encourage anyone interested in advanced augmentation techniques to seek guidance, as hands-on experience and mentorship are invaluable.
I encourage anyone interested in advanced augmentation techniques to seek guidance, as hands-on experience and mentorship are invaluable.
To conclude…
In summary, vertical and horizontal bone and soft tissue reconstruction are pivotal in achieving successful implant outcomes, especially in cases of significant bone loss. By understanding the biological principles behind tissue stability and employing techniques like GBR, the Sausage Technique, and Khoury Plates, we can ensure lasting, aesthetically pleasing results. However, these complex procedures require expertise, careful protocol adherence, and consistent follow-up care.
Investing in specialised training and mentorship is worthwhile for those eager to explore advanced tissue reconstruction more deeply. Through continued learning and collaboration, I hope we can raise the standard of care and achieve even better outcomes for our patients in implant dentistry.
You can watch the entire webinar with Nik Vourakis here. Chairside Visitation with Nik is available for ten surgical procedures, including GBR, sinus elevation, and oral surgery. For more information, click here.
