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ePaper created 2018-03-14, 10:36:46 | version 1.38.0
I C.E. article_ labial soft-tissue recession Fig. 6 _Screw ‘tent-pole’grafting technique; placement of three titanium tenting screws placed 3-4 mm below the gingival margin. Fig. 7_Placement of a mineralized allograft material over the defect site with coverage with a pericardial membrane. Fig. 8_Re-entry at four months after grafting showing excellent graft healing and consolidation over the previous defect. Fig. 9_The middle implant at the maxillary right central incisor position was removed in the second surgery to create a pontic site. 06 I implants 1_2018 Fig. 6 Fig. 7 Fig. 8 Fig. 9 apical migration and partial resorption of the aug- mentation material during remodeling (Fig. 7). Prior to use, the allograft material was hydrated according to the manufacturer’s directions and mixed with the patient’s blood, which served as a coagulant. After graft placement, the material was covered with a percardial membrane. The mucoperiosteal flap was approximated and sutured in place. The patient was provided with an interim prosthesis to be worn during four months of healing and was dismissed with postoperative instructions, antibiotics and analgesics until the follow-up visit seven to 10 days later. After a four-month healing period, a second- stage surgery was performed to remove the middle implant in the maxillary right central incisor position to create a pontic site (Figs. 8-9). The “screw tent- pole” technique was again utilized with mineralized allograft and a collagen membrane for additional vertical augmentation of the pontic site (Figs. 10-11). A consolidation period of 12 months was allowed to ensure proper maturation of the bone and overlying soft tissue (Fig. 12). Screw-retained provisional resto- ration were utilized (Fig. 13) for six months to develop the soft-tissue architecture prior to the delivery of the definitive restoration (Fig. 14). The final restoration with soft-tissue profile is shown at eight years (Figs. 15-16) and 13 years (Fig. 17) follow-up, along with CBCT and periapical views (Fig. 18-20). There were no complications or adverse events during surgery or postoperative healing. The preoperative crestal bone thickness for both implants increased to 1.8 mm and 2 mm, respectively, approxi- mately one year after treatment. Significant increases in soft-tissue thickness, keratinized tissue width and gingival height were also unexpectedly achieved and maintained through 12 years of follow-up. _Discussion This clinical case reports on unexpected improve- ments in peri-implant soft-tissue dimensions after GBR procedures to correct labial dehiscences around implants in the maxillary anterior jaw. Peri-implant bone loss can result in soft-tissue resorption fol- lowed by plaque attachment at or near the implant- abutment interface. This, in turn, can trigger soft- tissue inflammation with additional bone loss and gingival recession.16-20 It has been reported that gin- gival margin levels may be affected by the thickness of the gingival tissues and that a thin tissue biotype may favor apical displacement of the soft tissue margin.21 To maintain gingival health, maintaining an adequate width (~2 mm) of keratinized gingiva around dental implants has been suggested;16,19,21 however, this has been disputed.22 A correlation has been reported be- tween the presence of keratinized tissue and plaque levels and the incidence of mucositis.20 It has been