Mastering vertical hard and soft tissue reconstruction in implant dentistry
Nik Vourakis encourages implant dentists to check in on their level of experience in performing hard and soft tissue augmentation procedures. He provides an overview of the key principles and how to apply them to more complex procedures.
Bone and soft tissue augmentation are critical for creating a stable foundation for dental implants. In short, bone augmentation aims to restore the residual bone to its original volume, ensuring safe implant placement.
In contrast, soft tissue augmentation enhances the quantity and quality of tissue around the implant, resulting in a natural and aesthetic appearance. Both elements are vital for long-lasting results, requiring at least 2mm of bone around the implant and a thick layer of keratinised mucosa for long-term survival.
Soft tissue augmentation enhances the quantity and quality of tissue around the implant, resulting in a natural and aesthetic appearance.
Fundamental principles of bone augmentation
Bone augmentation seeks to reconstruct a deficient ridge to ensure an implant and aesthetically pleasing restoration can be constructed.
Bone grafting techniques
- Guided Bone Regeneration (GBR): This method employs bone grafts and membranes to stabilise and maintain space for new bone growth. GBR requires stability, angiogenesis, space maintenance, and tension-free closure. Biomaterials used include autogenous bone, allografts, xenografts, and synthetic materials, with autogenous bone being the gold standard due to its osteogenic, osteoinductive and osteoconductive properties.
- Block grafts: Harvested from the patient’s own bone, block grafts provide substantial bone volume and are particularly useful in severe bone deficiencies. Techniques like the Khoury technique involve splitting a bone block to form cortical plates, which are then fixed in place and filled with bone particles.
Horizontal and vertical augmentation:
- Horizontal augmentation: Addresses width deficiencies using techniques like the sausage technique, which involves a resorbable collagen membrane stabilised with pins, autogenous bone particles and biomaterials.
- Vertical augmentation: More challenging due to the need to overcome gravity and tissue tension, a staged approach using non-resorbable PTFE membranes with autogenous bone and biomaterials is often recommended.
Soft tissue augmentation techniques
Soft tissue augmentation is crucial for ensuring both functional and aesthetic outcomes in dental implant therapy.
Connective tissue grafts:
- Free gingival grafts: Harvested from the hard palate or tuberosity, these grafts are used to increase the thickness of keratinised mucosa, essential for maintaining peri-implant health and preventing recession. The advantage is the increase in keratinised tissue width, although donor-site morbidity and colour mismatch with the recipient site can be downsides.
- Connective tissue grafts (CTGs): Tissue is harvested from under the epithelial layer of the palate and placed beneath a partial-thickness flap at the recipient site. CTGs offer a better colour match, less donor site morbidity and improved aesthetics, though the procedure is more technically demanding.
Flap design and management
In the posterior mandible, a buccal safety flap with incisions and a loose lingual flap is often used. In the anterior maxilla, which is more demanding, additional small incisions are made for tension-free closure. Proper flap design ensures adequate blood supply and minimises complications. The use of microsutures and techniques such as the double-layer suture can help secure the graft and flap, promoting stable healing. Careful handling of the flap is needed to preserve the periosteal blood supply.
The use of microsutures and techniques such as the double-layer suture can help secure the graft and flap, promoting stable healing
Addressing post-extraction bone volume changes
Post-extraction bone loss is a significant challenge, with studies showing dramatic reductions in bone volume within weeks. Techniques such as flapless extraction help preserve bone volume by minimising trauma and maintaining blood supply.
Infection protocol: Early detection and intervention are crucial. The standard protocol includes removing the membrane, debriding infected graft material, applying local antibiotics, and re-evaluating the site after a few weeks to decide on further grafting.
Patient communication and follow-up: Clear communication about potential risks and complications is essential. Regular follow-ups, particularly within the first six weeks post-procedure, help monitor and address any issues early.
Training and best practices
Successful vertical hard and soft tissue reconstruction in implant dentistry requires a deep understanding of biological principles, advanced surgical techniques, and effective complication management. Continuous education and training are essential for dental professionals to stay updated with the latest advancements and best practices, ensuring optimal patient care and implant success.
Dentists should progress from simpler to more complex procedures. Training programmes and mentorship opportunities provide hands-on experience and detailed guidance on advanced grafting techniques, building confidence and competence. Maintaining a sterile environment and adhering to stringent aseptic protocols are paramount. This includes meticulous surgical techniques and post-operative care to prevent infections and ensure successful outcomes.
