Edited and Presented

by
Prof. Dr. Yasser EL Makaky
Professor of Periodontology and Implantology, Tanta University, Egypt
Professor of Periodontology and Implantology, MUST University, Egypt
Former Professor of Periodontology and Implantology, Taibah University ,KSA
Certified Trainer in Italian Membership of Implantology , Genova University, Italy
Certified Trainer in British Membership of Oral and Maxillofacial Surgery
Dental Implants are today considered as a reliable treatment option
to replace missing teeth both for esthetics and function.

The success of an implant restoration depends on proper implant

placement and the hard and soft tissue architecture that surrounds
the fixture and its gums, shape, color and texture which must
coordinate with adjacent teeth that close to the state of the nature.
 For an implant restoration to closely mimic the lost dental structure, it is
undoubtedly important to select the proper shape and contour of the
prosthetic tooth.

It is imperative to surround the crown with healthy, gingival-like tissue.

The presence of a thick cortical bone is one of the prerequisites for obtaining
an adequate gingival profile.
“Gingival cuff” is maintaining a competent seal of the surrounding
dental implants or abutments.

It has an important role to play in achieving long term complication-

free service of dental implant
 The differences between the peri-implant mucosa and the gingival
tissue.

The mucosa that encircles the fixture has more collagen and fewer fibroblasts,
with a 2:1 ratio, when compared with the periodontal gingival tissue

The peri-implant tissue had a higher fiber content and a lower cellular content
than that of gingiva around teeth.
The collagen fibers were
arranged parallel to the
titanium surface.

The collagen fibers of the

gingiva tended to be
arranged perpendicular to
the cementum surface of
the tooth root with other
fiber groups arranged in
various patterns.
 Vascular Supply
The supracrestal vascular surrounding the fixture is reduce and diversely
arranged
The connective containing few blood vessels
 Features Teeth Implant

Probing Depth Normal 2-3 mm Increased ≥ 4mm

Clinical Bleeding In Probing Reliable inflammatory sign Less reliable as bleeding is
Characteristic unrelated to the amount of
inflammation in the peri-implant
tissue
CT composition Low collagen and high fibroblast High Collagen and low fibroblast
Vascular Supply Increased (supraperiodsteal, vascular
plexus of PDL) Less (supraperiosteal only)
Tissue Quality Hard Tissue Interface Resilient connection Rigid Connection
Bone-periodontal ligament Osseointergration
connection Periodontal ligament & cementum
Others are absent
Periodontal ligament can allow tooth No adaptive capacity and no
movements with its adaptive capacity movements possible
Soft Tissue Connective Tissue Perpendicular insertion into Collagen fibers parallel to the
Interface Fibers cementum teeth surface
 Factors Affecting Esthetic of Implant

Anatomic Technical Surgical

•The width and position of •Improper implant • Careful and low-

the attached gingiva selection trauma soft
•the level and configuration tissue handling
of the gingival margin; and •The mal-
the size and shape of the positioning of • Implant
papillae dental implants placement in a
• The buccal volume of the proper position
alveolar process •Skill of the
•Horizontal or vertical bone operator • Precise wound
deficiencies closure
 1- The Relationship Between Biotype and Biologic
Width
Biotype is one of the critical Gingival biotype is the thickness of the
factors that determine the result of gingiva in the faciopalatal dimension .
dental treatment. Initial gingival 1.Thin gingival biotype
thickness predicts the outcome of any
2.Thick gingival biotype.
root coverage procedures or any
restorative treatments. Thick gingival biotype when the
thickness of the buccal mucosa is larger
than or equal to 1.5 mm.
The thicker biotype of the gingival Probe visibility is the clinical gold
mucosa has the more enough space
standard to discriminate thick biotypes
to support biologic width, besides the
from thin ones, but this method is prone
support of more blood supply.
to subjective interpretation.
 Characteristics of Thin Gingiva Characteristics of Thick Gingiva
Narrow zone of keratinized tissue Large amount of keratinized tissue
Gingival thickness is < 1.5mm, width is 3.5-5mm Gingival thickness is > 2.0mm,width is 5-6mm

Pronounced scalloped soft tissue and bony Flat soft tissue and bony architecture
architecture
Slight gingival recession Gingival margins usually are coronal to the
cementoenamel junction
Dehiscence and Fenestrations are usual findings in Thick bony plates
thin underlying bone
Thin marginal bone Thick marginal bone
Small proximal contact areas located near the Broad, more apically located contact areas
incisal edge
Triangular anatomic crowns Square anatomic crowns
Slender tooth forms Quadratic tooth form
Gingival recession following disease
 2- Thickness of labial bone wall

Esthetic effect obtained in the labial  There is about a 5–7 mm reduction in

gingiva is closely related to labial the alveolar bone crest, over a 6–12-
lateral bone wall thickness. Thickness month period, most of the reduction
greater than 2mm gives greater takes place in the first 4 months.
certainty of aesthetic effect and
implant stability.  There is a reduction in the vertical
dimension of the alveolar bone of
approximately 2–4.5 mm.
Most of the bone resorption which
takes place is in a bucco-lingual
dimension  The resorption which takes place may
be increased in sockets of molars and in
multiple adjacent extraction sockets
 Extraction Socket

Intact Socket

Labial bone Labial bone Defect Socket

thickness more thickness less
than 1 mm than 1 mm
Labial bone Labial bone
defect less than defect more
Immediate Ridge than 13 mm
preservation with 13 mm in
implant in mesial-
graft without mesial-distal
placement distal width of
membrane width of the
socket the socket

Ridge preservation Ridge preservation

with graft without with graft with
membrane membrane
 3- Distance between implants
The long-term success of restorative it is difficult to form gingival papilla when the
implants is based upon the biology and distance between implant edges or the
horizontal distance between adjacent teeth is
vasculature of bone surrounding the
less than 3 mm. The inter-implant distance
implants, especially the bone between should not be less than 3 mm and the
two implants. The ideal lateral space distance between the natural teeth and
between implants and tooth is 3-4 mm. implants should be at least 1.5 mm

To ensure that the peri-implant is

surrounded by the integrity of alveolar bone.
 4- Distance between Crown contact point-alveolar bones
(CPB)
It is the distance between the crowns of the teeth to the crest of bone. CPB less than
or equal to 5 mm results in an ideal esthetic effect.

If CPB is less than or equal to 4 mm, gingival

papilla recovery is 100%;
if CPB is greater than 4 mm but less than or equal
to 5 mm, average gingival papilla recovery is up to
88%; if CPB is greater than 5 mm, gingival papilla
recovery is less than 50%.

In maxillary anterior teeth area single tooth implant

restoration, controlling CPB to less than or equal to
4 mm, can avoid the "black triangle".
 5- The keratinized gingival tissue

The presence of gingival-like tissue

around the implants has several
important advantages.
The keratinized gingival tissue
provides a tight fibrous collar that
surrounds the implant, sealing off the
bacteria from the depth of the peri-
implant sulcus
Keratinized gums around the natural
tooth and implant play several The relationship between gingival and
important roles periodontal health proposed that in order to
maintain healthy gums, one must have a 2mm
 Withstanding mechanical friction wide keratinized gum, including 1 mm of free
and avulsion gingiva and 1 mm of attached gingiva.
 Counteracting adjacent tension of
the fraenum linguae When it was less than 2 mm, there was
 Stabilizing the gingival margin,
obvious gingival recession.
preventing plaque retention
 Buffering the biological forces from
the mucous membrane of muscle
fibers.
 Notice the
difference

The presence of
keratinized gingival tissue
provides a tight fibrous
collar that surrounds the
implant, sealing off the
bacteria from the depth
of the peri-implant sulcus
 Peri-implant mucositis:
(soft tissue inflammation
only)

Peri-implantitis: (soft &

hard tissue inflammation)
A number of risk factors have been identified that may lead to the
establishment and progression of peri-implant mucositis and peri-
implantitis.

 Previous periodontal disease

 Poor plaque control
 Smoking
 Genetic factors
 Diabetes
 Occlusal Overload
 Cement left behind following cementation of the crowns
 when these same parameters are present
From a clinical standpoint, signs that with any degree of detectable bone loss
determine the presence of peri-implant following the initial bone remodeling after
mucositis include: implant placement, a diagnosis of peri-
 Bleeding on probing and/or implantitis is made.
suppuration,
 Probing depths › 4 mm This can only be applied for cases where
 No evidence of radiographic loss of there has been a baseline radiograph
bone beyond bone remodeling. obtained at the time of supra structure
placement.
In those cases where this baseline radiograph
Peri-implant mucositis is reversible with is absent to use a threshold vertical distance
early intervention and removal of of 2 mm from the expected marginal bone
etiology level following remodeling post-implant
placement as the threshold for diagnosing
peri-implantitis
 The classification of peri-implant mucositis and peri-implantitis.
Staging Definition
Stage 0A PPD ≤ 4 mm and BoP and/or SUP, with no signs of loss of supporting bone following
initial bone remodeling during healing
Stage 0B PPD > 4 mm and BoP and/or SUP, with no signs of loss of supporting bone following
initial bone remodeling during healing
Staging Definition
Stage I BoP and/or SUP and bone loss ≤ 3 mm beyond biological bone remodeling
Stage II BoP and/or SUP and bone loss > 3 mm and < 5 mm beyond biological bone
remodeling
Stage III BoP and/or SUP and bone loss ≥ 5 mm beyond biological bone remodeling

Stage IV BoP and/or SUP and bone loss ≥ 50% of the implant length* beyond biological
bone remodeling
 Diagnosis & treatment options??
Probing, clinical & radiographic evaluation

Treatment:
1. Non surgical
2. Surgical & regenerative (hard and soft
tissue)

Current evidence has shown that non-

Parallelized intraoral X-rays should be used surgical therapy for peri-implantitis is
in all dental implants to determine possible minimally effective even with the
marginal bone loss. adjunctive use of locally delivered or
These periapical X-rays must be obtained at systemic antibiotics
implant placement and prosthesis
installation in order to allow comparisons
 Surgical access is usually required.
The primary objective of surgical intervention is to allow the surgeon to instrument the
implant surface and to perform debridement and decontamination.
Decontamination and detoxification of the implant surface can be performed
chemically or mechanically.
Reported methods include the use of:
Air power abrasives
lasers, saline wash
Ultrasonic use, The use of chlorhexidine and hydrogen peroxide
These are usually combined with flap surgery

Surgical procedures that have included the use of:

 bone regenerative procedures with barrier membranes
 bone substitutes, and growth factors, such as enamel matrix
derivative
 platelet derived growth factors
 In Implant Dentistry

When we do not perform comprehensive treatment plan

We plan for complications

The implantologist need to recreate the biological
status of natural tooth

To ensure the long term success for dental implant

Pre implant tissue stability
Esthetics has become a major concern in periodontal therapy.

In addition to appropriate function, esthetics are highly important in dental

implant treatments.

A key to an aesthetically pleasant smile is proper management of the soft

tissues around natural teeth or implants.
The criteria of aesthetic soft-tissue contour
 harmoniously scalloped gingival line
 The avoidance of an abrupt change in clinical crown length between
adjacent teeth.
 Convex buccal mucosa of sufficient thickness and a distinct inter dental
papilla.
The Clinical Tricks to Maintain Pre Implant
Tissue Stability
 Preoperative Clinical and Radiographic
Examination

Cone beam computed tomography CBCT scans evaluating;

• The length and thickness of the alveolus in order to select the adequate
implant length and diameter.

• Presence of enough interproximal bone.

 The clinical examination evaluating

 Gingival biotype

Thick ones ( ≥ 1.5mm) have obvious advantages in preventing the

withdrawal of fibrous tissue and bone tissue, besides more favorable
for masking the prosthetic component.
  Keratinized mucosa width (KMW):

At least 2mm wide keratinized gum, including 1 mm of free gingival and 1

mm of attached gingiva must be present around implant.
  Condition of adjacent teeth:

 Periodontitis in adjacent teeth resulting in alveolar bone resorption, which

may lead to reduced or absent papilla between implants.
 The Implant Placement

 Bucco-lingual & Mesio-distal

A facial malposition of the implant must be avoided.

  Corono-apically

I. 1 mm sub-crestal to the buccal bone plate (bone level as a reference).

II. 3-4 mm apical to facial gingival margin (soft‐tissue margin as a reference)

III. 3 mm apical to the line connecting the cementoenaml junction CEJ of

surrounding teeth
 The Surgical Technique
In ideal conditions implant placement should be performed flapless to
avoid recession of the mid-facial mucosa.
Use of incision designs such as the papilla preservation flap further helps to
preserve any existing tissue (Roll flap at implant second stage surgery).
Peri-Implant Surgery
 The goal

These techniques directed to peri-implant esthetic defects, such as ;

I. The absence of keratinized tissue.

II. Papilla alteration.

III. Loss of soft tissue thickness.

IV. Excess of peri-implant tissue.

V. Exposure of the prosthetic component.

 Preoperative Care

at the patient level, primary diseases of soft and hard tissues

must be under control and systemic risk factors such as smoking or poor
controlled diabetes must be addressed.
 Basic periodontal treatment for all cases: According to the diagnosis
of periodontal disease, appropriate treatment is performed.

Patients with periodontitis should be previously treated with nonsurgical

and surgical procedures when necessary.

Patients with gingivitis should undergo nonsurgical treatment sessions,

depending on the severity of the case.
Patients without periodontal disease should undergo a prophylaxis session
and comprehensive oral hygiene instructions 1 week before surgery.

Re-evaluation will be conducted after 4 weeks to evaluate the patient

response to phase therapy.
Complementary examinations: Even for patients reporting good systemic
health, complete blood count and coagulation tests and glycated
hemoglobin should be ordered.

Chlorhexidine rinse: All patients should rinse with 0.12% chlorhexidine

solution twice a day starting 2 days before surgery.
 Medication
1) Antibiotic prophylaxis should be administered in patients with
systemic risk.

2) A single dose of the steroidal anti-inflammatory drug

(corticosteroid).

3) Analgesics.
 Postoperative Care
Periodontal dressing is used only on the continuous suture of the palate.
Although periodontal dressing delays healing, patients report greater comfort
in the first postoperative hours.
 Instructions should also be formalized in writing or via email,
emphasizing the following:
1)Ice application to regions adjacent to surgery on the day of the
procedure.

2)Stop brushing/flossing in the operated region.

3)Do not chew on the side corresponding to the surgery.

4)Return to usual brushing in the operated area after the third

postoperative week, or as otherwise directed by the doctor.

5)Sutures were removed after 7 days.

Times at which peri-implant plastic surgery may be
performed

Before implant placement

Before tooth extraction
Patients with teeth with uncertain prognosis, deep recessions, and thin
periodontal phenotype may undergo root coverage surgery before
extraction.
 During tooth extraction

The tooth with a poor prognosis should be

 Removed with minimally invasive procedures

 The socket preservation (with an appropriate grafting material when

indicated).

 The association of SCTGs prevent postoperative tissue retraction

 subsequent temporization (with an ovate pontic)

The ovate pontic can serve another important periodontal function by
maintaining the interdental papilla next to abutment teeth after
extraction.

By inserting the correct pontic form 2.5 mm into the extraction site, At 4
weeks, the 2.5-mm extension can be reduced to a 1- to 1.5-mm extension
to facilitate hygiene.

This procedure can maintain the papilla next to the abutment teeth as
long as the bone on the abutment tooth is at a normal level.
 After tooth extraction

Alveolar ridges with no or little keratinized tissue and inadequate

bone volume can be grafted with SCTGs before receiving large bone
grafts, as there would be difficulty in moving the flaps and
inadequate nutrition for bone formation.
 During implant placement

Patients with a thin periodontal phenotype, even with sufficient bone,

should receive SCTGs simultaneously with implant placement and
subsequent temporization with subcritical contour to accommodate the
new tissue thickness.
 After implant placement
Esthetic defects of peri-implant soft tissues such as
Recessions
Papilla deficiency
Insufficient/thin keratinized tissue
Asymmetry of the gingival zeniths

can be detected only when the provisional / final crown is

being placed.
CLINICAL CASES
 CASE 1

Mandibular site demonstrating inadequate keratinized

mucosa, planned for implant restoration.

Implant placement followed by free gingival graft harvest

from palate.
 CASE 2

In the clinical examination, gingival recession and loss in soft tissue

thickness on the buccal aspect of the implant site were evident, as
well as discrepancies between the gingival and peri-implant zeniths
of the anterior teeth due to shortening of the clinical crown of the
right central incisor and tissue recession of the left incisors.
Surgical planning was considered SCTG for coverage the recession of
the left central and lateral incisors and increase the thickness of
soft tissue associated with crown lengthening of the right central
incisor.
 CASE 3

Patient presented with a missing

maxillary left central incisor. In
the clinical examination, there is
deficiency of the buccal soft
tissue contour of the
edentulous area was noted.
Sub epithelium connective tissue graft was divided into two
parts ; smaller part was sutured to the most concave part in
the defect while the larger part was sutured from the center
of mesial papillae to center of the distal papillae.
The patient has an Use a free
implant-supported gingival graft to
restoration 12 years increase the
ago, now complains amount of
about discomfort keratinized
during oral hygiene tissue.
procedures

A thick, free gingival

graft is carefully
adapted to the Final healing
periosteal bed &
stabilized with 5-0
gut sutures.
 Contact Information

+2 01555013680

+966 547048493

[email protected]
[email protected]
THANK YOU