Fouad Khoury

Bone and Soft Tissue

Augmentation
in Implantology

With contributions from:

R. Gruber, Th. Hanser, Ph. Keeve, Ch. Khoury, J. Neugebauer, J. E. Zöller
  

Fouad Khoury

Bone and Soft Tissue

Augmentation
in Implantology
With contributions from:
R. Gruber, Th. Hanser, Ph. Keeve, Ch. Khoury, J. Neugebauer, J. E. Zöller
A CIP record for this book is available from the British Library.
ISBN: 978-1-78698-104-2

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Foreword

The replacement of failed and missing teeth such as the bone core technique and the bony
with dental implants is a common and well-ac- lid approach. His clinical philosophy has also
cepted treatment modality. The success and stressed that successful bone augmentation re-
long-term stability of dental implants is directly quires impeccable soft tissue management.
related to the quantity and quality of the sup- This outstanding new book presents tech-
porting bone and surrounding soft tissue. When niques for more routine treatment as well as
there is a lack of adequate bone volume for im- some of the most challenging cases a clinician
plant placement, a variety of bone augmenta- might encounter.
tion procedures and materials have been pro- Prof. Khoury has assembled a team of re-
posed to develop the site. Although no single spected academicians and expert clinicians to
technique or biomaterial is optimal for every complete the text. A comprehensive understand-
clinical situation, autogenous bone continues to ing of bone biology is fundamental to developing
be considered the gold standard of graft mater- a rationale for clinical decisions. Prof. Reinhard
ials, and this text exemplifies this mantra. Gruber has done a wonderful job laying the
Prof. Dr. Fouad Khoury is a world-renowned foundation by explaining the biology of bone
authority in the fields of oral surgery and dental ­regeneration and the unique characteristics of
implantology. He is a unique blend of gifted autogenous bone. The book continues with clin-
clinician and inspiring teacher. Prof. Khoury is ical topics written by Dr. Thomas ­ Hanser, Dr.
Chairman and Director of the Privatklinik Philip Keeve, Prof. Charles Khoury, Prof. Joerg
Schloss Schellenstein in Olsberg, Germany, and ­Neugebauer, and Prof. Joachim Zoeller, includ-
Professor in the Department of Oral and Maxil- ing diagnosis and treatment planning, soft tis-
lofacial Surgery at the University of Muenster. sue management, autogenous bone harvesting,
Prof. Khoury is a skilled and exceptional sur- complex implant-supported rehabilitation, risk
geon who has dedicated his career to develop- factors, and complications. The procedures are
ing innovative techniques using auto­ genous well documented in a clear and precise manner
bone for augmentation of the deficient ridge. with high-quality photographs and extensive
His knowledge of bone biology spurred the de- references. Many of the chapters address the
velopment of the split cortical bone block pro- interdisciplinary aspects of treatment, which is
tocol, often referred to as the ‘Khoury bone critical in managing more complex cases.
plate’ technique. This novel approach has been Prof. Khoury is one of the most generous and
well proven as a very predictable method for the humble teachers I have encountered in dentist-
three-dimensional reconstruction of the maxilla ry. For decades he has not only thoughtfully
and mandible. Prof. Khoury’s perspective on treated patients but shared his vast knowledge
the importance of autogenous bone led to his and experience with students and clinicians
development of other bone grafting procedures around the world in classrooms and c­ onferences.

v
Foreword

He has also been devoted to documentation that Prof. Khoury and his team have shared their
and long-term follow up of his cases to scientif- expertise in this new third edition.
ically support his philosophy of treatment. This
text is just one example of his lifetime commit- Craig M. Misch, DDS, MDS
ment and dedication to teaching. May 2021
It is been a distinct honor to get to know
Prof. Khoury over the years as an esteemed col- Private Practice in Oral and Maxillofacial
league and friend. We have shared a similar ­Surgery and Prosthodontics
perspective on the importance of autologous Misch Implant Dentistry, Sarasota, FL
tissue for predictable augmentation and long-
term outcomes. Clinical Associate Professor
I would like to thank and congratulate Prof. University of Michigan, School of Dentistry
Khoury and his co-authors for their contributions University of Alabama at Birmingham, School
and this achievement. This superb text will serve of Dentistry
as an invaluable reference for students and fac- University of Pennsylvania, School of Dental
ulty as well as clinicians in the treatment of Medicine
their implant patients. We are indeed fortunate University of Florida, College of Dentistry

vi
  

Foreword of the first edition

Implant dentistry has evolved into a highly pre- ist’s approach to their patients’ problems. We
dictable clinical procedure in routine cases should remember to take a step back now and
where the available bone is of adequate height then and look at a therapy as a unified whole,
and width. However, this condition is not met not just at a sequence of treatment steps, im-
by all of our patients. Yet even patients with an portant as they may be.
inadequate bone supply to support implants Dr. Khoury is one of the most innovative sur-
now want – even expect – improved function geons that I know. For decades, he has been at
and better esthetics. the forefront of new and creative ideas to help
This superb textbook presents treatment his patients. He has also been kind enough to
techniques both for routine cases and for some share these innovations with the rest of the
of the most difficult cases a dentist is likely to world. This book is just one example of his life-
encounter. Dr. Fouad Khoury is one of the elite time commitment to teaching.
clinicians in oral and maxillofacial surgery. He He and his co-authors are to be congratulat-
is a true talent. He is supremely knowledgeable ed for this outstanding effort. It is the work of a
about every clinical aspect of transplantation, lifetime put down on paper for all of us to look
and his approach is impeccably scientific. He is at, think about, and – most importantly – use in
a rare blend of superb clinician and gifted the treatment of our patients. By sharing with
teacher. us their thoughts about what works and what
For this book, Dr. Khoury was able to enlist does not, Dr. Khoury and his team have truly
the assistance of a wonderful group of teachers advanced the cause of dentistry. We are grateful
and academics. They have done an excellent and thank them for all of their hard work.
job of sharing their knowledge and experience.
They have described their treatment procedures Dennis P. Tarnow, DDS
in a clear and precise manner, including exten- 2006
sive references at the end of each chapter. In
addition, many of the chapters address the in- Professor and Chairman
terdisciplinary aspects of treatment – which de- Department of Periodontology and
serves particular praise, since too many clin- Implant Dentistry
icians tend to be locked into their own special- New York University College of Dentistry

vii
 Preface

Oral rehabilitation supported by dental im- (cortical) and osteogenic (cancellous) properties,
plants is today an important column of restora- allowing early revascularization and functional
tive dentistry. Since the first scientific-based remodeling, with low complication rates that
publications in the early 1960s, many improve- are unequalled by any allograft, xenograft, or
ments in materials and techniques, especially alloplastic material.
in the augmentative field, have occurred. In- Through better understanding of the biologic
creasing patient demand for perfect esthetic processes of bone healing, including cell
and functional rehabilitations, even in difficult interaction, vascular supply, and bone re­
anatomical situations, has led to the develop- modeling, and in combination with some
ment of different methods that today allow for modifications of the surgical procedures, it is
the fulfillment of almost all patient desires for possible today to offer an implant-supported
a restoration that not only mimics the original restoration to almost all patients. Alveolar bone
anatomical situation, but gives an even better is reconstructed in a safe and reproducible
long-term result. manner, even in cases of severe bone loss, so
During the past 30 years, different tech- that, following prosthetic planning, a secure
niques and materials have been recommended and correct implant insertion can be performed.
for the reconstruction of alveolar defects such Long-term results of such implants inserted in
as autogenous, allogenic or alloplastic bone regenerated bone are providing similar success
grafts. Although the actual evolution of allo­ rates to implants inserted in non-grafted bone.
genic, xenogenic, and alloplastic materials, in Different techniques and modifications for
combination with guided tissue regeneration augmentation with intraorally harvested bone
techniques, is progressing from day to day, grafts have been developed over the past three
­reproducibility and predictable long-term prog- decades with predictable long-term results.
noses are still limited in comparison with These techniques cover almost all situations,
­autogenous bone, which is still the gold stan- starting with a minimally invasive approach
dard. The main problem of xenografts and al- with locally harvested bone grafts up to the
lografts, especially in block form, is their poor extremely complicated 3D reconstruction of the
ability for revascularization. This leads to sever- whole maxilla and/or mandible.
al early as well as late complications and fail- This is the third book I have edited on bone
ures in the contaminated oral cavity. augmentation in oral implantology. The first one
Compared with other bone substitutes, the was published in 2006 in English, and the
superiority of autogenous bone has been second came out in 2009/2010 in more than
demonstrated on a biologic, immunologic, and 10 languages. In this new edition on bone
even medicolegal basis. Due to graft morphology, augmentation and soft tissue management in
autogenous bone has additional mechanical oral implantology, the focus is principally on the

viii
 Preface

techniques that were developed and modified at Acknowledgments

our hospital over the past three decades and
documented long term by our team. Firstly, thank you to all my contributors for their
The first chapter deals with the biology of excellent cooperation and the high quality of their
bone healing especially after grafting procedures, work. In addition, I would like to thank all my
and the second with descriptions of diagnostics alumni, not only for their help in the treatment of
and treatment planning. Soft tissue management complex cases but also in the precise
in combination with bone augmentation is a very documentation of the long-term results, including
important topic with a great influence on the suc- superb-quality clinical images. In particular, I
cess of the grafting procedure. For this reason, would like to single out my co-worker, Dr. Thomas
the third chapter plays an exceptional role in the Hanser, for his friendship and unwavering loyalty.
new edition, with important step-by-step details Over the past 26 years I have had about 38
of the different techniques. The central topic and postgraduate students and residents from
most important part of the book is, of course, the different countries following our oral surgery
fourth chapter on safe bone harvesting and pre- program. These alumni as well as the actual co-
dictable grafting procedures for all kinds of bone workers and residents are: Dr. Friedrich Pape
deficiencies, starting with minimally invasive (head of the Restorative Department in Olsberg
techniques for augmentation of small bony de- and responsible for most of the prosthetically
fects up to the extensive bone augmentation of treated cases presented in this book), Dr. Frank
severe 3D bone loss. All the techniques are Spiegelberg, PD Dr. Arndt Happe, Dr. Alessandro
demonstrated step by step with numerous clinic- Ponte (Turin, Italy & Lugano, Switzerland), Dr.
al images, allowing a good and easy understand- Klaus Engelke, Dr. Stefan Bihl, Dr. Frank Berger,
ing of the described methods. Documented long- Dr. Jochen Tunkel, Dr. Luca de Stavola (Padova,
term results of the different techniques, up to Italy), Dr. Pierre Keller (Strasbourg, France), Dr.
27 years post­operat­ively, are presented as they Herman Hidajat, Dr. Jenny Schmidt, Dr Şerif
appear, with both radiographic and clinical imag- Küçük, Dr. Frank Zastrow, Dr. Joel Nettey-Marbel,
es. The book contains a special chapter with the Dr. Ayoub Alsifawo (Libya), Dr. Alexander
focus on our restorative concept for the treatment Friedberg, Dr. Ingmar Braun, Dr. Stefano Trasarti
of patients with complex restorations in combin­ (Teramo, Italy), Dr. Romain Doliveux (Lyon,
ation with extensive bone grafting procedures, France), Dr. Marco Vuko Tokic (Croatia), Thuy-
which also explains the procedures step by step, Duong Do-Quang (Netherlands), Dr. Jan Jansohn,
from the temporary until the definitive restor- Dr. David Wiss (Vienna, Austria), Dr. Michael
ation. The last chapter discusses the possible Berthold, Dr. Elisabeth Schmidtmayer, Dr. Philip
risks and complications, in combination with the Keeve, Dr. Valentin Loriod (Besançon, France),
grafting procedures explaining how to deal with Dr. Erik Faragó (Budapest, Hungry), Dr. Christopher
such risks as well as the possibilities of how to Schmid, Dr. Andrea Savo (Rome, Italy), Dr. Oliver
prevent or to treat complications. Dresbach, Dr. Kathrin Spindler, Dr. Alexander
In this new edition I would like to present Zastera, Dr. Sarah Römer, and Dr. Jan Wildenhof.
our clinical knowledge based on biologic Special thanks to my previous co-workers, Dr.
principles as well as our long-term experience, Carsten Becker, for his help with the digital
for those interested in extending their clinical transformation of analog figures as well as for the
skills and scientific background in order to offer excellent illustrations of some surgical techniques
their patients the best possible treatment in (see Chapter 3), and Dr. Tobias Terpelle, for his
terms of bone and soft tissue augmentation. tremendous support for the chapter on restorative

ix
Preface

procedures. In addition, I would like to thank the and editing as well as to Mrs. Ina Steinbrück for
whole team of the Privatklinik Schloss the perfect layout.
Schellenstein in Olsberg for their help and loyalty Finally, the most important thanks are for my
during the past three decades. wife, Michaela, and my children, Chantal, Elias,
Thanks also to the further Director of the and Chérine, for their love, great support, and
Department of Cranio-Maxillofacial Surgery, endless understanding.
University Hospital Münster, Prof. Dr. mult.
Ulrich Joos, as well as to the actual Director,
Prof. Dr. Dr. Johannes Kleinheinz, for their
scientific support.
My sincere thanks go to the entire team at
Quintessence Publishing, especially Dr. Horst W.
Haase, Mr. Christian Haase, Mr. Johannes Wolters,
and Mrs. Anita Hattenbach, for their support and
patience over the years. Many thanks also to Fouad Khoury
Mrs. Avril du Plessis for the excellent correction Olsberg, Easter 2021

x
  

Editors and Contributors

Editor KHOURY Charles, DDS, DES, CES, M.Sc.

KHOURY Fouad, DMD, PhD Professor
Director Department of Prosthodontics
Privatklinik Schloss Schellenstein School of Dentistry
Olsberg, Germany; St. Joseph University, Beirut, Lebanon
Professor
Department of Cranio-Maxillofacial Surgery NEUGEBAUER Joerg, DMD, PhD
University Hospital Münster, Germany Professor
Steinbeis University Berlin, Transfer-Institut,
Management of Dental and Oral Medicine;
Senior Academic Lecturer
Contributors (in alphabetical order) Interdisciplinary Department for Oral Surgery
GRUBER Reinhard, DMD, PhD and Implantology
Professor and Chair Department of Craniomaxillofacial and Plastic
Department of Oral Biology Surgery
School of Dentistry University of Cologne, Germany;
Medical University of Vienna, Austria Senior Oral Surgeon
Group Office for Implantology, Dr. Bayer and
HANSER Thomas, DMD, M.Sc. colleagues, Landsberg am Lech, Germany
Deputy Director
Privatklinik Schloss Schellenstein ZOELLER Joachim, MD, DMD, PhD
Olsberg, Germany; Professor and Chairman
Senior Academic Lecturer Interdisciplinary Department for Oral Surgery
Department of Postgraduate Education and Implantology
Goethe University Frankfurt, Germany Department of Craniomaxillofacial and Plastic
Surgery
KEEVE Philip L., DMD, M.Sc. University of Cologne, Germany
Private Office for Periodontology and Oral
Surgery
Hameln, Germany

xi
 Table of Contents

Foreword v 3 Soft tissue management and

bone augmentation in
Foreword of the first edition vi
implantology 75
Preface vii
3.1 Introduction 76
Acknowledgments viii 3.2 The basics of incisions, suturing
Editors and Contributors xi techniques, and soft tissue healing 80
3.3 Instruments 84
3.4 Soft tissue management before
1 Biology of bone regeneration in augmentation 85
augmentative procedures 1 3.5 Soft tissue management during
augmentation and implantation 104
Reinhard Gruber 1 3.6 Soft tissue management during
1.1 Introduction 2 implant exposure 155
1.2 Cells of bone remodeling 3 3.7 Soft tissue management following
1.3 Biology of bone regeneration 7 prosthetic restoration 187
1.4 Autograft resorption 14 3.8 References 197
1.5 Osteoconductive characteristics of
autografts 15
4 Mandibular bone block grafts:
1.6 Osteogenic properties of autografts 15
diagnosis, instrumentation,
1.7 Osteoinductive properties of
harvesting techniques, and
autografts 16
surgical procedures 205
1.8 Summary 17
1.9 References 18 4.1 Introduction 206
4.2 Biologic procedure for mandibular
bone grafting 206
2 Diagnosis and planning of
4.3 Techniques and methods for
the augmentation procedure 23
intraoral bone harvesting 229
2.1 Introduction 24 4.4 Augmentation techniques 314
2.2 Patient consultation 26 4.5 Bone remodeling and volume
2.3 Anamnesis 26 changes after grafting 449
2.4 Specific findings 34 4.6 Conclusion 459
2.5 Choice of grafting technique 54 4.7 References 472
2.6 Conclusion 62
2.7 References 70

xii
 Table of contents

Special Appendix 477 7 Complex implant-supported

rehabilitation from the
A. Use of the maxillary tuberosity (MT) temporary to the definitive
in the immediate dentoalveolar restoration 553
restoration (IDR) technique 478
References 479 7.1 Introduction 554
B. The palatal bone block graft (PBBG) 482 7.2 Specific aspects of temporary
References 483 restorations 554
C. Alumni case reports 485 7.3 Treatment planning 557
7.4 Classification of temporary
restorations 559
5 Bone grafts from extraoral sites 499
7.5 Restorative concept 576
5.1 Introduction 500 7.6 Fixed complex restoration:
5.2 Bone harvesting from the calvaria 500 step by step 587
5.3 Bone harvesting from the tibia 504 7.7 Long-term provisional 589
5.4 Bone harvesting from the iliac crest 511 7.8 Surgical procedures 589
5.5 References 531 7.9 Final restoration 592
7.10 Concluding remarks 599
7.11 References 606
6 Clinical and scientific
background of tissue
regeneration via alveolar 8 Risk factors and complications
callus distraction 535 in bone grafting procedures 611
6.1 Introduction 536 8.1 Introduction 612
6.2 History of the callus distraction 536 8.2 Risk factors 612
6.3 Principles of the callus distraction 537 8.3 Intraoperative complications 629
6.4 Devices 538 8.4 Postoperative complications 663
6.5 Surgical technique 538 8.5 Complications during implant
6.6 Distraction in different areas 544 placement after bone grafting 704
6.4 Conclusion 546 8.6 Complications during implant
6.5 References 550 exposure 716
8.7 Late complications after prosthetic
restoration 721
8.8 References 736

Index 745

xiii
 3
Soft tissue management
and bone augmentation
in implantology
Soft tissue management during
augmentation, implantation, and
second-stage surgery
3 Soft tissue management and bone augmentation in implantology

3.1 Introduction parameters such as bleeding on probing (BoP),

probing depth, and radiographic bone loss may
In addition to purely functional rehabilitation, be worse if the keratinized mucosa is miss-
the esthetic quality of implant treatments is ing.115 In a study by Keeve and Khoury94 on a
­becoming increasingly important in modern im- sample of 77 patients with altogether 105 im-
plantology. Above all, patients consider the plants over an average observation period of
­appearance of peri-implant soft tissue and pros- 8 years, a statistically less significant degree of
thetic superstructures to be decisive.181 plaque accumulation, recessions, and mucosal
The care and preservation of existing soft and inflammation around implants with at least
hard tissue is, of course, essential for esthetical- 2 mm of attached mucosa were observed.94 Due
ly appealing implantology for prosthetic purpos- to the structural anatomical differences be-
es. In many cases where tissue cannot be pre- tween teeth and implants, which mostly consist
served, functional and esthetic results are not of missing supracrestal fibers attaching to the
possible without bone augmentation in combi- root in the case of titanium or ceramic surfaces,
nation with corresponding soft tissue manage- compromised transmucosal attachment can be
ment. A preoperative esthetic analysis is recom- expected around implants already after expo-
mended in almost all cases to ensure that the sure.158 The best possible fixation of the muco-
implant is positioned anatomically correctly and sa surrounding implants can, at the very least,
is presented in an optimal manner relative to the ensure better daily plaque control and reduce
adjacent teeth and soft tissue. Soft tissue man- the related inflammatory processes.178 The ke-
agement is therefore decisive in all surgical in- ratinization of the tissue in visible areas is in-
terventions for the overall result of augmentative dispensable for esthetic reasons (e.g. with a
treatment. view to the formation of recessions), and is es-
According to Rosenquist,149 there are four sential for the functional and esthetic success
factors that fundamentally determine the func- of an implant. It is certainly recommended to
tional and esthetic appearance of soft tissue: 1) create keratinized, or at least attached, mucosa
the width and position of the attached kerati- of an adequate width during implantation or ex-
nized gingiva; 2) the buccal volume and con- posure surgery.
tour of the alveolar process; 3) the height and The other important aspect of soft tissue
profile of the gingival margin; and 4) the size management is the thickness of the peri-implant
and appearance of the interdental and inter- mucosa. Scientific studies have proven that one
implant papillae. However, esthetic results are should aim for a minimum height of at least
often poorly documented in the literature and 2 mm.117 A systematic review confirmed that
are rarely taken into account as a criterion of thicker peri-implant soft tissue layers (> 2 to
treatment success.16 Notwithstanding, the ade- 3 mm) result in significantly less bone loss
quate width of the attached and/or keratinized around implants.171,178 It is therefore reasonable
mucosa was (and is) regularly discussed in the to prepare not only the width but also the thick-
clinical literature. A systematic review found ness of the attached soft tissue cuff – particular-
that the amount of plaque accumulation, muco- ly in esthetic areas – in a manner that enables
sal inflammation, recessions, and loss of at- optimal long-term success rates.
tachment were more expressed to a statistically The size and form of the papillae adjacent
significant extent around implants where the to implants are determined by anatomical, sur-
width of keratinized mucosa was inade- gical, and restorative factors. To minimize
quate.115,147 It has to be noted, however, that interimplant bone resorption after prosthetic

76
 3.1 Introduction

treatment and prevent a significantly greater the grafted area. In many cases, it is important
degree of bone loss, the distance between two to improve the quality and quantity of the soft
implants should be no less than 3 mm, and that tissue before a bone grafting procedure.
between an implant and a natural tooth no less A periosteal incision in line with the Rehr-
than 1.5 mm.65,176 mann technique increases the elasticity of the
Interdental papillae are present in 98% of flap, so that its edges can be closed with exter-
cases if the distance between the Limbus alve- nal horizontal mattress sutures or simple inter-
olaris and the approximal contact point of the rupted sutures without tension in a two-layered
prosthesis is less than 5 mm. If the distance is procedure. The disadvantage of this procedure
increased to 6 to 7 mm, the stability of the is the coronal adaptation of the mucogingival
papilla is reduced, and exists in 56% and 27% junction during augmentation and implanta-
of cases, respectively.177 tion, which has to be subsequently corrected for
The formation of papillae between adjacent esthetic and functional reasons by a second or
implants is more problematic. The size of inter- third implant-exposure procedure.97 Soft tissue
implant papillae can only be predicted up to a management therefore plays a decisive role in
distance of 3 mm between the alveolar bone and restoring functional and esthetic soft tissue
the contact point.53 A papilla can probably form harmony.
between an implant and a tooth at a correspond-
ing vertical distance of 4.5 mm.152,175
In the case of pontic solutions, however, 3.1.1 Anatomy and vascularization of the
papilla height is predictable at a distance of soft tissue
5.5 to 6 mm between the alveolar bone and the An understanding of the macro- and micro-ana-
contact point.152 These anatomical indices are tomical structure of periodontal and peri-im-
considered indispensable, but they do not plant tissue is a prerequisite for understanding
guarantee the formation of a papilla after sur- the principles of plastic soft tissue surgery and
gical procedures.190 exposure techniques. The different anatomical
Soft tissue management is a very important aspects are briefly presented and explained in
factor in bone augmentation for the following the following sub-sections.
reasons: 1) for the primary safety of the proced-
ure; 2) for the esthetic result in the anterior 3.1.1.1 Gingiva
area, since bony defects are also combined with The gingiva consists of gingival connective tis-
poor soft tissue quality; 3) for function, reducing sue and overlying epithelium. With the excep-
the muscle activity around the grafted bone and tion of interdental cols, its surface is keratinized.
the implants; and 4) for the long-term stability The gingiva is located between the gingival mar-
of the definitive results. Primary, tension-free gin and the mucogingival junction. The thick-
wound closure is indispensable in augmentation ness of this layer is between 1 and 9 mm,23 with
measures – bone grafts or guided tissue regen- an average thickness of about 1 mm.52 It is
eration – and is a decisive prerequisite for the thickest in the maxillary anterior region and
bacteria-free healing of the graft as well as for thinnest in the mandibular lingual area.5 The
an eventually successful treatment. Gingiva width of the gingiva is significantly influenced
quantity and quality are important factors, not by the position of the teeth,151 and changes with
only for good primary healing of the grafted bone jaw growth.9 The orthodontic movement of the
to reduce the risk of tissue necrosis and graft teeth in a bucco-oral direction can therefore cor-
exposure, but also for the long-term stability of respondingly influence the gingival width.10

77
3 Soft tissue management and bone augmentation in implantology

The keratinized, stratified, squamous epi- 3.1.1.2 Peri-implant mucosa

thelium reaches up to the cementoenamel The size, shape, and anatomy of the peri-im-
junction and goes over into the sulcus epitheli- plant soft tissue depends on wound healing de-
um to a physiologic depth of about 0.5 mm in termined by the position of the implant and by
the direction of the periodontal space. The oral the implant system and exposure techniques
sulcus epithelium is histologically similar to used. It is comparable to the clinical character-
the gingival epithelium but is less parakerati- istics of soft tissue around natural teeth.18,112,155
nized. It is adjoined at the bottom of the sulcus It has to be taken into account that instead of
by the marginal epithelium, with an epithelial a periodontal ligament with physiologic mobility
attachment of 1 to 2 mm in width on the sur- in relation to the anchorage, the implant has an
face of the enamel. The marginal epithelium is osseointegrative connection with the alveolar
stratified and non-keratinized and has a very bone. As a result, the peri-implant connective tis-
high turnover rate.156 It is completely regener- sue fibers around the abutment or the surface of
ated every 4 to 6 days by proliferating cell lay- the implant are arranged in a parallel position in
ers. If the marginal epithelia of adjacent teeth the supracrestal area, as opposed to being an-
or implants adjoin, a non-keratinized col of a chored to the dental root cementum.1,2,17,18
papilla is formed.81 This takes on a saddle-like Peri-implant connective tissue also has a higher
shape in the interdental area and is dependent ratio of collagen fibers and a lower ratio of fibro-
on the shape and dimensions of the approximal blasts, and as such is very similar to scar tissue
contact point. The function of the marginal ep- in histomorphologic terms.124,157
ithelium is to protect the underlying bone from While the vascular supply of the gingiva is se-
penetrating micro-organisms. This contact and cured from the three anastomosing areas of the
reaction zone ensures that the organism per- interdental septa, the periodontal ligament, and
forms immunologic engagement with chemo- the oral mucosa, peri-implant connective tissue
taxis and humoral defense away from the shows a relatively low level of vascularization. As
bones. a result of osseointegration, the vessels from the
This attached gingiva reaching up to the periodontal ligament no longer exist, which means
mucogingival junction does not shift relative to that the vascular supply of the peri-implant mu-
the alveolar process, and the connective tissue cosa is almost exclusively ensured through su-
matrix consists of collagen fibers to about 60%. praperiosteal vessels and a small number of ves-
It forms the supra-alveolar and supracrestal fi- sels emerging from the bone.19 External bone
ber apparatus of the tooth or implant. The col- surfaces are covered by a thin, inelastic layer of
lagen fibers are attached to the teeth in connective tissue that is rich in collagen – the
three-dimensional (3D) structures. They have a so-called ‘periosteum.’ In addition to osteoblasts,
stabilizing function as regards the position of osteoclasts, and the corresponding precursor
the teeth, and act as a functional unit of the cells, the periosteum also contains a large num-
periodontium in the root cementum and the al- ber of blood vessels and nerves, which are of par-
veolar bone.66 ticular significance for the regeneration of the
The keratinization of the gingival epithelium freshly augmented bone, and may only be sepa-
does not result from functional wear but is rath- rated during exposure measures above the im-
er determined by genetic factors in the underly- plant cover screws with the greatest possible care
ing connective tissue.91,92 as regards the insertion of the gingiva former.
In particular, during surgical soft tissue man-
agement around implants, the scarred histo­

78
 3.1 Introduction

morphometry of the implant, the lack of an- from the 3D inflammatory infiltrate.54,55 Howev-
chored fibers, and the comparatively poor er, vertical bone loss is still to be expected, in
vascularization of peri-implant mucosa should particular in the case of two-part implant sys-
in consequence be taken into account. Based on tems. It reaches to about 2 mm apical to the
these differences, a reduced resistance to me- junction,75-77 whereas the material of the abut-
chanical and microbiologic impacts as well as a ment also has an influence on the transmucosal
compromised healing potential after surgical in- soft tissue.158
terventions can be expected due to the poorer Independent of the design of implants, it has
vascular supply.116 therefore been recommended that peri-implant
soft tissue should have a thickness of at least
3.1.1.3 Biologic width 2 to 3 mm following exposure measures, in the
The special structure of the gingival tissue around interest of protective immune reactions. Also, a
teeth and implants is a unique anatomical situa- response of the organism can be expected in
tion, where epithelial integrity is in­terrupted. This cases of increased peri-implant bone loss.30,39
involves the formation of a combination of epithe- The goal of placing gingiva formers or abut-
lial attachment against microbiological impacts ments during exposure surgery is to change the
and a connective tissue attachment against me- horizontal dimension of biologic width in line
chanical impacts, which is referred to as biologic with the platform-switching principle, and
width.84 there­by ensure the preservation of the peri­
Around teeth, the biologic width has a verti- implant bone tissue.36,110 Bone preservation
cal dimension of 2.04 mm, of which an average should be further enhanced by replacing gin­
of 1.07 mm consists of connective tissue at- giva formers and abutments as infrequently as
tachment and 0.97 mm of epithelial attach- possible, with the least possible trauma to
ment.66 Following exposure, a biologic width trans­mucosal soft tissue.1 Biologic width should
also forms around implants. The connective tis- therefore always be taken into consideration,
sue attachment around implants is very constant also in relation to implants. Without hard tissue
compared with that of teeth, and has a width of support, damage to the biologic width would
about 1 mm, while the epithelial attachment – become visible in the long run and would result
also called the long marginal epithelium – is in undesirable esthetic phenomena such as re-
significantly wider.157 The long marginal epithe- cessions and papillae losses.
lium forms a connection to the implant or the
abutment surface through hemidesmosomes 3.1.1.4 Tissue biotype
and internal basal lamina. From a clinical point of view, periodontal tissue
Animal experiments have shown that, inde- biotypes can be classified in terms of form, pro-
pendent of closed or open healing, a small de- file, and thickness. Normal, thick, and thin bio-
gree of vertical bone loss can be expected around types are distinguished.161 Thick biotypes have a
implants, at an average of 1.1 to 1.3 mm apical flat bone and gingiva profile with a significant
to the implant–abutment junction.54-56 A coronal width of keratinized gingiva. Rectangular and
plaque-related and connection-related inflam- quadratic tooth forms co-occur here, and there is
matory infiltrate was discovered in the microgap a correlation with thicker buccal alveolar walls.169
between the abutment and the implant. Despite For this reason, bone dehiscence or fenestration
the topographic proximity of the crestal bone, a is less frequently observed with thick biotypes.
physiologic band of connective tissue has al- Thin biotypes can be identified on the basis of a
ways been found. This band shields the bone steeper, garland-like gingiva profile, with a ten-

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3 Soft tissue management and bone augmentation in implantology

dency for triangular tooth forms and a smaller and radiographic bone loss.115 Despite the study
width of keratinized gingiva. Patients with a thin- by Keeve and Khoury94 referred to above, most
ner biotype are classified as high-risk because scientific studies do not assess success criteria
they have a significantly greater risk of develop- but implant survival rates, based on which it is
ing not only buccal but also approximal reces- still difficult to show whether attached mucosa
sions such as locus minoris resistentiae, which results in any improvement. The present authors
can be the result of multiple causes (i.e. trau- strongly recommend the restoration of attached
ma).61,185 Thin biotypes can be converted into mucosa as an important objective of exposure
thick ones with augmentative techniques, and techniques. The keratinization of tissue and the
the related risks can be minimized. resulting protective effect – also against the for-
A direct measurement of the tissue biotype mation of recessions – is indispensable, in par-
and its thickness can be performed by way of a ticular for esthetic reasons and for the preserva-
clinical test based on the ‘transparency of the tion of a pale pink, dimpled, and keratinized
periodontal probe.’49 surface around implants that is free of inflam-
mation, i.e. appealing ‘pink esthetics.’
3.1.1.5 Attached and keratinized tissue
The formation of keratinized gingiva around
teeth is considered a biologic development pro- 3.2 The basics of incisions,
cess due to the genetic determination of basal
suturing techniques, and soft
lamina and is therefore always present, at least
tissue healing
in a minimal form. However, this phenomenon
has to be created in peri-implant tissue using The aim of soft tissue healing is a good esthetic
appropriate exposure techniques. and functional final result, which includes com-
Since Lang and Loe106 proved in 1972 that plete morphofunctional restoration modeled on
teeth show more significant inflammatory phe- original structures. The incision, the formation
nomena if the width of the keratinized gingiva is of the flap, wound margin management, and su-
less than 2 mm, this threshold has been regard- turing techniques have to be carefully consid-
ed as an adequate size for maintaining peri- ered in order to optimize flap healing and trans-
odontal health. Wennström and Lindhe183,184 plant receptivity and reduce scarring, especially
proved in animal experiments that the size and in the esthetic area.
apical dimension of the inflammatory infiltrate Principally, there are intraorally – and de-
and the incidence of periodontal attachment pending on the indication – two flap designs:
losses do not differ between patients with an n The full-thickness flap, including mucosa,
adequate width of keratinized gingiva and those muscle, and periosteum. This kind of flap,
with an inadequate width. A systematic review also known as the mucoperiosteal flap, is
found that the amount of plaque accumulation, the most frequently used for intraoral sur-
mucosal inflammation, recessions, and loss of geries, including bone augmentation.
attachment were more expressed to a statistical- n The partial-thickness flap, involving the
ly significant extent around implants where the mucosa alone or including the muscle. This
width of keratinized mucosa was inade- kind of flap requires the surgeon to be more
quate.115,148 However, it also has to be noted experienced in preparing a mucosal layer
that an inadequate width of keratinized mucosa over the muscle. It is indicated in some
does not give rise to any noticeable negative ef- special surgeries, leaving the periosteum on
fects on parameters such as BoP, probing depth, the bone, and is known as the Kazanjian

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 3.2 The basics of incisions, suturing techniques, and soft tissue healing

Fig 3-1a Exposure of the mental nerve is a prerequisite Fig 3-1b Blood vessels running perpendicular to the
in every implant or augmentation surgery in the area of bone.
the mandibular premolars/first molar.

Fig 3-1c Important ramifications of the lingual artery in

the mandibular anterior area.

Fig 3-1d Typical incision in the middle of the crest in the

edentulous maxilla, with the releasing incision in the fren-
ulum for implant and augmentation surgery, preserving a
sufficient vascular supply for good postoperative healing.

vestibuloplasty, the bone extension plasty n Incisions have to take into consideration
(see Chapter 4) or the lateral approach for the course of the blood vessels, on the one
bone augmentation. hand retaining the maximum vasculariza-
tion of the flap, and on the other, avoiding
Incisions and flap design for bone augmenta- heavy bleeding during the surgery (Fig 3-1c
tion and implant insertion must respect the and d).
general rules of surgery: n Incisions and flap design must offer the best
n Incisions have to avoid the injury of import- possible vision and access for the surgeon.
ant anatomical structures such as nerves or n Incisions must offer a wide flap basis to re-
important blood vessels (Fig 3-1a and b). duce the risk of flap necrosis.

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3 Soft tissue management and bone augmentation in implantology

Fig 3-1e Intensive scar tissue formation in the maxillary Fig 3-1f Clinical situation in the right mandible 2 weeks
anterior area after horizontal incisions (further postoperatively: incision in the middle of the crest sutured
apicoectomies). with 6-0 monofilament resorbable sutures.

n Incisions and flap design should reduce the 3.2.1 Cellular and molecular healing
risk of scar tissue, especially in the esthetic mechanisms
area (Fig 3-1e).
n Atraumatic incisions, flap preparation, and Wound healing involves both the repair and the
sutures without any tension are important regeneration of the damaged tissue. The inflam-
factors to reduce the risk of flap necrosis matory healing process mainly consists of reep-
(Fig 3-1f). ithelialization, neoangiogenesis, and the activa-
tion of connective tissue cells, which also gives
Two wound-healing processes are distinguished rise to the degradation of the proteins in the
in the context of exposure measures. In the case extracellular matrix and their resynthesis.159
of primary wound healing (per primam intentio- The regulation of these processes is determined
nem), the wound margins should be correctly re- by interactions between proteins of the matrix
positioned throughout, which results in the di- and epithelial cells as well as cytokines and
rect closure of the superficial wound layers growth factors. After these three wound-healing
through the formation of a fibrin network, with phases are complete, the result is either an area
optimal fibrinogen synthesis and neoangiogene- of scar tissue formed by repair healing or an
sis. The tensile strength of the tissue is, however, area of exact regeneration by original morpho-
only restored after the complete healing of the logically functional tissue.
submucosa after about 1 to 3 weeks. In contrast,
submucosal granulation tissue grows over tissue 3.2.1.1 Inflammation phase (day 0 to 3)
continuity defects in the case of secondary A brief vasoconstriction and the formation of
wound healing (per secundam intentionem), the blood clot from a plasmatic network of
which is determined by neutrophil polymorpho- thrombocytes and erythrocytes is followed by
nuclear leukocytes and macrophages until the increased vascular permeability and the release
final epithelialization of the wound. of cytokines. The fibrinogen synthesis in the
blood clot polymerizes fibrin and stimulates the
migration and proliferation of marginal epithe-
lial cells. Thrombocytes also release chemotac-
tic cytokines such as TNF-α and IL-1 for neu-

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 3.2 The basics of incisions, suturing techniques, and soft tissue healing

trophil granulocytes and macrophages.79 This 3.2.2 The reactions of tissue to sutures
immune response decontaminates the wound
by way of phagocytosis, cell-mediated immune Suture materials are a foreign body and inevita-
response, and peroxides, before lymphocyte-re- bly lead to mild inflammatory reactions in tissue,
cruiting macrophages enter the tissue. The which may locally reduce resistance to infec-
lymphocytic reaction follows antigen presenta- tions. Specifically, needle and thread penetration
tion specific to the molecular patterns of vari- sites represent biologic niches where bacterial
ous microorganisms. invasions are possible.6
Wound healing in the oral cavity involves a
3.2.1.2 Proliferative and fibroblastic phase higher risk of bacterial contamination, the so-
(day 3 to 12) called ‘wick effect.’ Biofilm formation therefore
The proliferation and migration activity of fibro- needs to be reduced as much as possible by
blasts is enhanced by growth factors expressed using monofilament threads. Suture materials
by macrophages and leads to increased colla- must possess high tensile strength and tear re-
gen synthesis and to neoangiogenesis triggered sistance, good knotting characteristics, and high
by VEGF and β-FGF.168 The reepithelialization knot strength.174 In this context, it was shown
of the wound margins restores the integrity of that atraumatic microsurgical application sig-
the anatomical structures. Integrins function nificantly supports flap and wound healing.25
as receptors for chemotactic factors, which in- The use of atraumatic monofilament suture
teract with collagen and fibronectin, and PDGF threads with a maximum thickness of 0.01 mm
of thrombocytes and TGF-β of macrophages (i.e. ≤ 6-0) is therefore indicated due to lower
activate mesenchymal cells and thereby the
­ levels of bacterial colonization,114 smaller histo-
formation of granulation tissue.44,79 Glyco­sa­mi­ logic inflammatory infiltrate, and the reduced
no­­glycans, proteoglycans, tenascin, and throm­ formation of scar tissue. At the time of the re-
bospondin invade the extracellular matrix, and moval of the sutures after 14 days, the epitheli-
myofibroblasts differentiate to contract the um is already keratinized,159 and the thread is
wound area. slightly colonized by rod- and spindle-shaped
bacteria. Due to the complex, multilevel sutur-
3.2.1.3 Maturation phase (day 6 to 14) ing techniques used to achieve esthetic and
Matrix metalloproteinases trigger collagenolysis functional results, it is recommended to use re-
and synthesis in order to reorganize the extracel- sorbable suture threads. Nevertheless, as the
lular matrix and granulation tissue. The fibroblas- metabolic degradation process takes approxi-
tic phase is determined by the formation of mately 60 days, these should be removed if ac-
type III and I collagen and improves the tensile cessible after 14 days. This results in greater
strength and elasticity of the new tissue. Integ- patient comfort and is obligatory in the particu-
rins in the cell membranes consolidate the provi- lar case of two-layer wound closure. The surgical
sional matrix through α- and β-heterodimer pro- needle should have a curve length of 11 to
teins and enable reepithelialization. Integrin 13 mm, and a triangular profile sharpened and
α5β1 not only stimulates adhesion and migration polished toward the tip. The needle should be
in this process, but also has a decisive effect on made of stainless steel to achieve the best pos-
cell growth through signaling.12,86,109 sible stability while causing the least possible
trauma to the tissue (Fig 3-2a to d).

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3 Soft tissue management and bone augmentation in implantology

Fig 3-2a Exposure of a 3D-form grafted bone in the anter- Fig 3-2b Insertion of two implants in the vertically grafted
ior maxilla 3 months postoperatively using the same incision bone.
line that was made during the grafting procedure, including
the releasing incision in the mesial third of the canine.

Fig 3-2c Wound closure with 6-0 monofilament resorb- Fig 3-2d Clinical situation 4 weeks postoperatively.
able sutures.

3.3 Instruments The shape of the instruments’ grip should be

round and well-balanced and have a length of at
Microsurgical concepts have become estab- least 16 cm. In particular, in the case of length-
lished in soft tissue management.46,189 Micro- ier procedures, such ergonomic work in the pos-
surgery is understood to mean surgical proced- terior sections of the jaw may have advantages.
ures that require optical magnification aids, Grips with a round profile make possible the
miniaturized instruments, and suturing mater- significantly more precise manipulation of in-
ials that have been adapted accordingly. The struments in the pencil-grip position.
atraumatic ­management of tissue and the opti- On the one hand, an incision without any
mal closure of wounds by way of microsurgical tissue loss is possible with a single-edged
techniques have produced significantly im- No. 15c blade with a pointed tip and adequate
proved results. The improved and predictable width in the case of two-layer dissections; on
wound healing process was described by Bur- the other hand, one could use a double-edged
khardt and Lang,25 who compared macrosurgi- SM69 micro scalpel. In the selection of raspa-
cal and microsurgical procedures. tories (e.g. Partsch Raspatories), a slender de-

84
 3.4 Soft tissue management before augmentation

Fig 3-3a Angulated scalpel for better access from the Fig 3-3b A supraperiosteal flap preparation in the poster-
palatal side. ior maxilla is made easier using an angulated scalpel.

sign is best. Larger raspatories can only be gentle locking mechanism. In the case of micro
used for the atraumatic lifting of flaps. There scissors, curved shapes with pointed blades
should be at least one anatomical and one sur- have proven to be practical.
gical forceps, the latter specifically designed Some special instruments, e.g. the multi-po-
for microsurgery. Without lip and muscle re- sitioned angulated scalpel, can be very useful
traction, a delicate flap, or a free or pedicle to gain access to different intraoral areas for
connective tissue graft, can be optimally held specific surgeries (Fig 3-3a and b).
using a surgical Cooley forceps without much
pressure. If too much pressure is applied in the
case of anatomical forceps, the delicate flap 3.4 Soft tissue management before
can be significantly traumatized or bruised. In
augmentation
the case of very thin flaps or free mucosal
grafts, an anatomical forceps is the best choice Inflammatory processes and tooth extractions
for atraumatic handling without the risk of per- sometimes lead to pronounced damage to both
foration. For knotting suture threads, either an hard and soft tissue. In particular, the quantity
anatomical or a surgical forceps with plateau is and quality of soft tissue, including its regener-
suitable to avoid any damage to the suture ma- ative characteristics, are severely compromised
terials when grabbing them. As regards the in cases involving infected biomaterials or failed
choice of needle holder, in addition to the nee- implantation attempts with multiple previous
dle size to be used, the level of experience and surgeries. It can be an advantage in all these
the preference of the surgeon play a decisive situations to improve the quality of soft tissue in
role. Various sizes of the required shape as well this region before actual augmentative mea-
as a slender design are needed to ensure ap- sures. This allows for an easier and safer clo-
propriate access to the interdental areas. Mi- sure, primarily in relation to vertical bone aug-
crosurgical needle holders are usually not mentations. Soft tissue improvement is most
equipped with a lock, although it is of great frequently indicated in patients with a thin gin-
help in oral and periodontal surgery for con- gival biotype, as the improved soft tissue has a
trolled rotating movements. The needle holder protective effect on the hard tissue graft and
by Castroviejo is, for example, equipped with a ensures a better long-term esthetic result.

85
3 Soft tissue management and bone augmentation in implantology

Fig 3-4a Poor esthetic situation after looseness of an Fig 3-4b After removal of the crown, explantation of the
implant at the position of the first left central incisor, and implant using the BTI explantation system (BTI, Vito-
bone and soft tissue loss on the implant at the position of ria-Gasteiz, Spain).
the lateral incisor.

Fig 3-4c Preparation of a pedicle Fig 3-4d The pedicle connective Fig 3-4e Wound closure with 6-0
connective tissue flap in the left tissue flap is tunneled under a soft sutures without any releasing
palate. tissue bridge to cover the defect and incision.
improve the quality of the soft tissue.

A thin biotype is easily diagnosed by prob-

ing, as the periodontal probe is visible through
the tissue, and it is a predisposing factor for the
formation of recessions. It may therefore be rea-
sonable to change biotypes from thin to thick,
with consideration of esthetics. This can be
achieved by both free gingival and connective
tissue grafts and palatal pedicle connective tis-
sue flaps (Fig 3-4a to l). Rotation flaps can be
created, epithelialized or deepithelialized from
Fig 3-4f Clinical situation 2 months postoperatively.
buccal mucosa or the palate. The volume and
quality of the soft tissue can also be improved

86
 3.4 Soft tissue management before augmentation

Fig 3-4g Exposure of the bony defect. Fig 3-4h Vertical bone augmentation with bone grafts
from the left mandibular retromolar area following the pro-
tocol of the SBB technique.

Fig 3-4i Closure of the wound with 6-0 monofilament Fig 3-4j Clinical appearance 3 months postoperatively.
sutures (only one releasing incision was necessary for the
wound closure).

Fig 3-4k Bone exposure using the same incision line Fig 3-4l Clinical situation after the definitive restoration.
made during the grafting procedure: insertion of two im-
plants in the grafted area.

87
3 Soft tissue management and bone augmentation in implantology

Fig 3-5a Soft tissue recession on the two mandibular Fig 3-5b Preparation of a partial thickness flap on the
central incisors and agenesia of the two lateral incisors. area of the lateral incisors, and tunneling the buccal mu-
cosa of the central incisors.

Fig 3-5c Connective tissue graft harvested from the pal- Fig 3-5d The connective tissue graft is placed under the
ate for the soft tissue augmentation. tunneled mucosa and stabilized with 6-0 sutures at the
area of the lateral incisors.

through free gingival and/or connective tissue zation opportunities. In the case of sulcular in-
grafts, which can at the same time counteract cisions, the blade cuts papillae directly under
shifts in the mucogingival junction. the tooth contact point, parallel to the tooth
axis, and the whole gingiva is incorporated into
the flap. Releasing incisions in the gingival mar-
3.4.1 Incisions before augmentation gin should be altogether avoided before aug-
From the very beginning, the adequacy of the mentation; the only exception is in the case of
cuts has great significance for the later esthetic auxiliary access incisions in the mucosa for the
success. If the existing tissue is thin, it is rec- placement of grafts. In the pre-augmentative
ommended to place the incision strictly vertical- phase, only mucosal flaps – also called
ly in order to achieve two equally thick flap mar- split-thickness flaps – should be used (Fig 3-5a
gins and thereby optimize suture closure, to o). If a thin layer of connective tissue and
healing, and the final results. Independent of periosteum are left on the bone, grafts heal bet-
the phase of soft tissue management, the inci- ter due to the vascular supply from all sides.134
sion should ensure the necessary accessibility of In addition, the resulting bone resorption can be
the operation site and offer the required mobili- minimized in the case of a split-thickness flap

88
 3.4 Soft tissue management before augmentation

Fig 3-5e Wound closure. Fig 3-5f Occlusal view of the grafted area.

Fig 3-5g Clinical appearance 6 weeks postoperatively. Fig 3-5h Occlusal view with the etched restoration.
The temporary restoration is performed as a Maryland
bridge.

Fig 3-5i Exposure of the atrophied crestal bone. Fig 3-5j Bone block harvesting from the apical area.

dissection, as compared with mucoperiosteal with the removal of foreign materials (e.g. bio-
flaps with denudation of bone.60,135,166,187 Excep- materials after infection). In such cases, the flap
tions to this concept are situations where the preparation must include bone exposure to re-
soft tissue augmentation has to be combined move the foreign materials.

89
3 Soft tissue management and bone augmentation in implantology

Fig 3-5k Bone grafting with simultaneous implant inser- Fig 3-5l Bone block grafting on the right side. Simultane-
tion on the left side. ous implant placement was not possible here.

Fig 3-5m Wound closure. Fig 3-5n After 3 months, implant insertion in the grafted
bone on the right side.

3.4.2 The split-thickness tunnel

technique

Soft tissue thickening is mostly achieved with

connective tissue grafts. The split-thickness
tunnel technique involves the use of free grafts
that restore volume, in particular on the vestib-
ular aspect of the defect, and therefore com-
pletely exclude the risk of exposure during later
augmentation measures. After the free connec-
tive tissue graft is harvested from the palate, the Fig 3-5o Definitive restoration performed by the referring
dentist.
graft bed is opened – beginning with a vertical
mucosal incision – and a Partsch Raspatory or
Kornman scissors are used to bluntly dissect a
tunnel toward the target site. The tunnel is cre- centered on soft tissue deficits and reaches the
ated to be 1.5 times the size of the excised keratinized areas of the gingiva, if necessary. If
graft, preserving the anatomical structures as the keratinized gingiva is very thin, a transition
much as possible (Fig 3-6a to e). The tunnel is into a mucoperiosteal flap at the mucogingival

90
 3.4 Soft tissue management before augmentation

Fig 3-6a High bone atrophy in the posterior mandible Fig 3-6b Tunnel preparation for soft tissue grafting.
with an extremely thin gingival biotype.

Fig 3-6c Connective tissue graft harvested from the pal- Fig 3-6d Clinical situation at the end of the surgery.
ate is prepared to be placed through the tunnel.

junction may be necessary to avoid perforations.

The graft is pulled in using a sling suture at the
distal end of the tunnel, which can then be
knotted in the same step to a mattress suture.
The graft should be fixed in the correct position
by at least two mattress sutures, with the use of
a few simple interrupted sutures to prevent rota-
tion before the vertical access incision can be
closed (Fig 3-7a to l).

Fig 3-6e Clinical situation 2 months postoperatively pre-

3.4.3 Free connective tissue grafts senting an improved soft tissue appearance prior to the
before augmentation bone grafting.

Connective tissue grafts are primarily harvested

from the lateral palate, independently of the be categorized into connective tissue grafts,
phase of soft tissue management. Further donor gingival grafts, and grafts, the last being a com-
sites include the tuber maxillae and the man- bination of the first two. The ‘lateral palate’ do-
dibular retromolar region. Free tissue grafts can nor site should, however, be further specified,

91
3 Soft tissue management and bone augmentation in implantology

Fig 3-7a Thin soft tissue biotype in the atrophied right Fig 3-7b Tunnel preparation on the vestibular side.
mandible.

Fig 3-7c Connective tissue graft harvested from the right Fig 3-7d Harvesting of a connective tissue graft from the
palate. right palate.

Fig 3-7e Wound closure in the right palate. Fig 3-7f The connective tissue graft is placed inside the
prepared tunnel.

as the tissue is thickest in the premolar region palatinus major at the approximal space of the
of the palate. Depending on the patient, subep- second and third molars,101 and continues an-
ithelial tissue grafts also include fatty and glan- teriorly at an average distance of 12 to 14 mm
dular tissue, in addition to collagenous areas from the gingival margin,123 depending on the
(Figs 3-5c and 3-7d). The palatine artery is to height of the palatal vault.142 The so-called ‘sin-
be preserved; it emerges from the foramen gle-incision technique’ has been preferred in

92
 3.4 Soft tissue management before augmentation

Fig 3-7g Wound closure. Fig 3-7h Clinical situation 2 months postoperatively.

Fig 3-7i Bone block grafting through the tunnel Fig 3-7j Postoperative radiograph.
approach.

Fig 3-7k Clinical situation 6 years postoperatively. Fig 3-7l Radiographic control 6 years postoperatively.

many described harvesting techniques used to margins can be optimally stabilized during later
dissect subepithelial grafts,83,107 as it has been suturing if the harvesting incision is 1 to 1.5 mm
found to improve postoperative healing and pa- from the first incision. Depending on the pa-
tient morbidity. The technique involves a hori- tient, a decision needs to be made as to wheth-
zontal incision on the palatal side, followed by er the graft should be elevated from the bone
a sharp undermining dissection. The wound bluntly or by using a further split-flap ­dissection.

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3 Soft tissue management and bone augmentation in implantology

Fig 3-8a Clinical situation before extraction of the left Fig 3-8b Occlusal appearance.
central incisor due to a length fracture.

In addition to own tissue-specific proteins,

autologous connective tissue grafts also con-
tain a significant number of fibroblasts, the
majority of which are accessible for initial plas-
matic circulation and the revascularization that
follows, for which reason they have a more fa-
vorable prognosis.

3.4.4 Punch technique

Fig 3-8c Clinical situation after atraumatic extraction of If there are no acute inflammatory symptoms,
the central incisor.
the so-called ‘punch technique’90 – involving a
combined graft consisting of connective tissue
and epithelial parts – can also be used for the
The blunt approach enables the excision of a closure of extraction or explantation alveoli. This
more voluminous and more stable graft, incor- technique results in an optimal stability of the
porating the periosteum but at the price of coagulum in the alveolus, and it compensates
slightly greater patient morbidity. For suture for the volume and keratinization of the soft tis-
care, a combination of continuous sling sutures, sue. The graft can be harvested from the tubera
simple interrupted sutures, and a palate plate is behind the last molar in cases where there is a
recommended (Fig 3-7e). wide keratinized gingiva in this area (Fig 3-8a to
If connective tissue with a higher ratio of col- j) or from the palate in the premolar area. In the
lagen and less fatty and glandular tissue is re- case of the palate, a rotated punch bur can be
quired, a deepithelialized gingival/connective used to facilitate the harvesting procedure
tissue graft is recommended. Alternatively, the (Fig 3-9a to l). In the case of the graft being
tuberosity region is recommended as a second- harvested from the tubera, an incision is made
ary donor site. Grafts gained using a distal wedge in the middle of the connective tissue area that
excision will shrink less due to their structure, will create two strips of connective tissue by
and have a special form, which makes revascu- keeping a central epithelial area, with a diame-
larization difficult. For this reason, the tuberosi- ter corresponding to that of the extraction sock-
ty region remains the secondary donor site. et. Split-thickness flaps are dissected without

94