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Journal of Oral Science & Rehabilitation Volume 2 | Issue 4/2016 29 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 soft-tissue template was delivered 24 h after surgical soft-tissue removal and the patient was asked to apply corticosteroid cream under the template b.i.d. for one month (Fig. 3). Subse- quently,the newtissue appeared more similarto the gingiva, with reduced thickness and greater attachment to the underlying bone (Figs. 4–6). One month later, implants were inserted with a flapless technique using a computer-guided im- plant template. Three to six months later, a de- finitivescrew-retainedimplant-supportedbridge was delivered. O u t c o m e m e a s u r e s w e r e : Implantfailure: Implantsthat hadto be removed at implant insertion owing to lack of stability, implant mobility, removal of stable implants dictated by prozgressive marginal bone loss or infection, and anytechnical complications (e.g., implant fracture), rendering the implant unus- able. The stability of individual implants was assessed at delivery ofthe definitive prosthesis by tightening the abutment screw at a torque of 20 N cm and 12 months after definitive pros- thesis delivery. Complications:Anybiological(pain, swelling, suppuration, etc.) and/ortechnical complication (fracture ofthe framework and/ortheveneering material, screwloosening, etc.)was considered. Periimplant mucosal response: Probing pocket depth (PPD) and bleeding on probing (BOP)were measured bya blinded operatorwith a periodontal probe (PCP-UNC 15, Hu-Friedy, Chicago, Ill., U.S.) 12 months after definitive prosthesis delivery. Three vestibular and three lingual values were collected for each implant and averaged at patient level. An independent hygienist performed all ofthe periodontal mea- surements. Results Six patients (four males and two females) with a mean age of 48.4 years were considered eligible andtreated.Atotalof32implants(NobelReplace Tapered Groovy, Nobel Biocare, Göteborg, Sweden), ranging from 8.0 mm to 16.0 mm in lengthandfrom3.5mmto5.0mminwidth,were placed. No dropout occurred during the entire follow-up period. No implantfailed andthe over- allimplant survivalratewas 100% oneyearafter definitive prosthesis delivery. All of the patients presented with healthy soft tissue, stable PPD and good BOP values at the one-year follow-up. ThemeanPPDandBOPvalueswere3.6±0.6mm and 9 ± 4.8%, respectively. Discussion Fibula and iliac crest osseomyocutaneous free flaps have been demonstratedto beveryreliable for the reconstruction of large composite facial defects after resection oftumors, osteoradione- crosis or gunshot trauma. Moreover, implant- supported prosthetic rehabilitation is reliable with this microvascular reconstructive option because of sufficient volume and good bone quality.4, 9 Nevertheless, prosthesis-based implant treatment still represents a major chal- lenge inthese difficult cases.The surgicalproce- dure forimplant placement can be more difficult owing to limited opening ofthe scar-contracted oral cavity or the presence of large volumes of soft tissue with little information on the profile of the underlying bone, which is necessary for a valid surgical guide. Moreover, the need to limit the exposure of frequently irradiated bone or scarredfieldsreducessurgicalprecision.Further- more, scars and the thickness of the soft tissue can interfere with the prosthetic procedures, such astaking fixture impressions, and maylead to imprecise results. A detailed soft-tissue analysis of these pa- tients is essential. It is clearthat normalattached gingiva and alveolar mucosa differ from soft tissue reconstructed with skin and muscle. A frequent complication arising from the recon- struction of intraoral soft tissue with skin is the hyperplastic/inflammatory response of the skin and subcutaneous tissue around implant abut- ments and the formation of a granulomatous tissue,whichmaycausepainandbleedingduring brushing. This phenomenon, Although no speci- fic data are available concerning this phenome- non,whichhasalreadybeendescribedbyothers,5 it is possible to speculate that the reconstructed skin is not a suitable tissue around implants and may react negatively in the oral environment. In our opinion, many of the techniques described for managing the transplanted tissue, such pa- latal epithelial connective tissue grafts or free skin grafts, present some limitations owing to the difficulty in obtaining a real engraftement. A unique solution to this problem does not exist andtherefore it requires an individualized appro- ach. The approach described in this article ap- pears to be useful especially because it does not Volume 2 | Issue 4/201629