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Journal of Oral Science & Rehabilitation Volume 2 | Issue 4/2016 27 P e r i i m p l a n t s o f t - t i s s u e m a n a g e m e n t Introduction Bone continuity defects after oncological jaw resection or for other reasons may result in a series of problems, such as facial contour disfig- urement, large oronasal and oroantral commu- nications, saliva retention, and impaired speech, swallowingandmastication.Fibulaandiliaccrest free flaps have demonstrated high reliability for reconstruction ofmandibularand maxillarylarge bone defects. They are used as both osseomus- cular and osseomyocutaneous flaps and allow the simultaneous reconstruction of bone conti- nuity and both intraoral (cheek mucosa, palate, floor of the mouth, etc.) and cutaneous (chin, cheek, etc.) soft-tissue deficiencies. 1, 2 Addition- ally, patients with oral cavity defects often pres- ent with loss of teeth and alveolar and basal jawbone, which can lead to significant impair- ment of mastication. With this microvascular reconstructive option, dental prosthetic rehabil- itation is possible even if the prosthesis-based rehabilitation remains a challenge.3, 4 Implant-baseddentalrestorationsinpatients reconstructedwithfibulaflaps have been shown to offer many benefits, such as sufficient stabi- lization of the prosthesis, even in patients with marked irregularities ofthe hard- and soft-tissue anatomy,andtheycancompensateforsmalllocal soft-tissue deficiencies, contributing to an im- proved aesthetic result (i.e., bysupportingthe lip profile). A recurring problem during implant- prosthesis rehabilitation after reconstruction with vascularized free flaps is the hyperplastic granulomatous reactive tissue that can grow aroundthe implant abutments ofthe prosthesis. The reconstructed soft tissue lacks the phy- siological properties and function of native mucosa. Normal attached gingiva and alveolar mucosadifferfromsofttissuereconstructedwith skin and muscle.Afterimplant-prosthesis resto- ration, excessive soft-tissue bulk, movement, chronicinflammationandhypertrophyarereadily observedaroundimplantsandriskcompromising the long-term implant success. This phenome- non, which has been described by others,5 is an unresolved problem.Various clinicalreports sug- gest different approaches, with contradictory results.6 Some have harvested keratinized mucosa from the hard palate and grafted it around the implants after removing the skin.7 Others prefer skin grafts associated with remodeling and deepening of the fornix. Both procedures are often associated with soft-tissue remodeling as a result of the prosthesis.7–9 The aim of the pre- sent pilot case series studywasto present a new technique for managing the periimplant soft tissue before implant placement, the soft-tissue template technique. Materials and methods This study was designed as a pilot case series study aimed at evaluating a new technique for periimplantsoft-tissuemanagement(soft-tissue template technique) in patients reconstructed with fibula free flaps after mandibular or maxil- lary resection for oncological reasons. Patients were selected and consecutively treated at the MaxillofacialSurgeryUnit, UniversityHospitalof Sassari, Sassari, Italy. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki of 1964 for biomedical research involving human subjects, as amended in 2008. The patients were duly informed about thenatureofthestudy.Writteninformedconsent to surgical treatment was obtained from each patient. Patientswerenotadmittedtothestudyifany of the following exclusion criteria were present: general contraindications to implant surgery; subjectedto irradiation inthe head and neck area lessthanoneyearbeforeimplantation;untreated periodontitis; signs or symptoms of cancer re- currence; poor oral hygiene and motivation; un- controlled diabetes; alcohol abuse; psychiatric problems or unrealistic expectations; active in- fection or severe inflammation in the area inten- dedforimplantplacement;andinabilitytoattend the follow-up visits. C l i n i c a l p r o c e d u r e s a n d d e s c r i p t i o n o f t h e t e c h n i q u e At least six months after reconstruction with a fibula free flap (Fig. 1), all crestal soft tissue, in- cluding skin and muscle, was removed, leaving only periosteum attached to the reconstructed alveolar crest (Fig. 2). Immediately after remov- ing the soft tissue, an impression was taken of the crest and residual teeth using a silicone ma- terial to customize an acrylic soft-tissue tem- plate. The template was shaped to cover the entire crest and have a large vestibular flange usedto deepenthe fornix.Asmall spacewas left between the crest and acrylic template. The Volume 2 | Issue 4/201627