Soft Tissue and
Esthetic Considerations in Implant Therapy
Following a discussion of the rationale and biologic basis for
creating a stable peri-implant soft tissue environment, the author presents a systematic approach
to the patient evaluation, including quantification of the positive and negative
elements that enhance and detract from an individual’s smile; specific surgical
maneuvers for managing peri-implant soft tissues, including various innovative
flap designs; the surgical and prosthetic protocols of a technique for
preserving the natural hard and soft tissue anatomy in patients undergoing tooth
removal; soft tissue grafting techniques for augmenting attached tissues around
natural teeth and implant restorations; and an innovative technique for
reconstructing large-volume hard and soft tissue defects in the anterior
maxillary area. The final chapter presents advanced cases that demonstrate the
use of these procedures in various situations, along with algorithms to guide
the implant surgeon in their selection and sequencing.
Table of Contents
Preface
Acknowledgments
Chapter 1: Beyond Osseointegration
• Anatomy and Biology of Peri-implant Soft Tissues
• Choosing Between a Submerged and Nonsubmerged Approach
Chapter 2: Systematic Evaluation of the Esthetic Implant Patient
• A Simplified Approach to Patient Evaluation
• Facial and Dental Symmetry
• Periodontal Biotype
• Anatomic Limitations
• Marginal Tissue Recession
• Classification of Alveolar Ridge Defects in Esthetic Implant Therapy
Chapter 3: Surgical Techniques for Management of Peri-implant Soft Tissues
• Instrumentation for Soft Tissue Management in Implant Therapy
• Criteria for Optimal Flap Design in Implant Therapy
• Application of Plastic Surgery Principles in Implant Therapy
• Flap Management Considerations
• Surgical Maneuvers for Management of Peri-implant Soft Tissues
• Flap Management Considerations for Mandibular Implant Surgery
• Flap Management Considerations for Maxillary Implant Surgery
• Flap Design and Management Considerations for Esthetic Implant Therapy
Chapter 4: The Bio-Col Technique
• The Importance of Site Preservation
• Bio-Col Technique for Delayed Implant Placement
• Bio-Col Technique for Immediate Implant Placement
• Long-Term Clinical Results Obtained with the Bio-Col Technique
• Suggested Refinements
• Summary
Chapter 5: Soft Tissue Grafting in Implant Therapy
• Periodontal Plastic Surgery
• Oral Soft Tissue Grafting with Dental Implants
• Modified Palatal Roll Technique for Dental Implants
• Epithelialized Palatal Graft Technique for Dental Implants
• Subepithelial Connective Tissue Graft Technique for Dental Implants
• Summary
Chapter 6: The Vascularized Interpositional Periosteal–Connective Tissue
(VIP-CT) Flap
• Rationale and Biologic Basis
• General Considerations
• Potential Complications
• Surgical Procedure
• Clinical Experience
• Summary
Chapter 7: Esthetic Implant Therapy: A Comprehensive Approach
• Philosophy of Care
• Rationale for Site Preservation
• Implant Site-Development Techniques
• Prosthetic Considerations for Enhancing Outcomes in Implant Therapy
• Surgical Considerations for Enhancing Outcomes in Implant Therapy
• Use of Platelet-Rich Plasma to Enhance Outcomes in Implant Therapy
• Conceptual Framework for Esthetic Implant Site Development
Appendix: Treatment Algorithms for Esthetic Implant Therapy
Index
Editorial Reviews
From Book News, Inc.
Sclar (a private practitioner specializing in oral,
maxillofacial, orthognathic, and periodontal plastic surgery) presents a
medical text that is at once an overview of the clinical/surgical soft
tissue issues surrounding the use of osseointegrated tooth implants, as well
as presentation of two new techniques--the Bio-Col alveolar ridge
preservation technique and the vascularized periosteal- connective tissue
flap. Pertinent scientific information and surgical anatomy is integrated
into the text. The reader is led through guidelines of the surgical stages
from evaluation, selection of instrumentation, surgical maneuvers, and peri-operative
careBook News, Inc.®, Portland, OR
Book Info
Provides practical guidelines and detailed information
concerning the surgical management of peri-implant soft tissues in
individual case situations and patient types. Although clinical in nature,
the scientific basis and pertinent surgical anatomy for the successful use
of techniques and treatment protocols are reinforced. DNLM: Dental
implantations--methods.
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Preface
Since Brånemark et al’s elucidation of the scientific basis for osseointegration
and the methodology for achieving long-term clinical success with
implant-supported restorations, the dental literature has been replete with
scientific and clinical information emphasizing refinements in implant hardware
and detailing the surgical techniques to achieve regeneration of alveolar bone.
As a result, the clinical applications of osseointegration have gradually been
expanded to include the treatment of edentulous maxillary arches, various
degrees of alveolar atrophy, and partial edentulism.
Although the immobility of the bone-implant interface was initially credited as
the breakthrough for overcoming the biologic soft tissue problems that plagued
predecessor implants anchored via fibrous encapsulation, the mechanism by which
a stable soft tissue environment developed around the osseointegrated implant
was far from understood. Furthermore, the detrimental effect of mobility of peri-implant
soft tissues on the long-term prognosis of an osseointegrated implant was either
ignored or greatly underestimated. As information concerning the anatomic
similarities and important differences between periodontal soft tissues and peri-implant
soft tissues became available, the profession made great strides in
understanding the biologic processes involved in the formation and maturation of
the structural relationship between the soft tissues and an emerging implant.
Through experience, clinicians were also gaining a greater appreciation for the
importance of establishing a stable peri-implant soft tissue environment. In
particular, when osseointegrated implants were first used for esthetic tooth
replacements, the lack of predictability and the unacceptable rate of
compromised outcomes underscored the importance of proper surgical and
prosthetic soft tissue management. While the profession focused on “magical
incisions and flap designs” that would ensure pleasing esthetic results, many
factors now known to play an important role, such as the history leading to
tooth loss and the periodontal phenotype, went largely unrecognized. Although
there was an evident lack of consensus in the implant literature regarding the
need for attached tissues around implant restorations, experienced clinicians
correlated the presence of attached (nonmobile) tissues with a decrease in soft
tissue–related complications, facilitation of prosthetic procedures for the
restorative dentist, and greater satisfaction by their patients.
Despite these developments, the need for practical guidelines and detailed
information concerning the surgical management of peri-implant soft tissues in
individual case situations and patient types has largely gone unanswered. This
book was written to fill that void. It combines original concepts and techniques
with information extrapolated from the specialties of oral and maxillofacial
surgery, plastic and reconstructive surgery, and periodontology. Although the
majority of the material covered is clinical in nature, the scientific basis and
pertinent surgical anatomy for the successful use of the techniques and
treatment protocols are introduced early on and reinforced throughout wherever
applicable.
The reader is led through a systematic evaluation of the esthetic implant
patient, including consideration of the various conditions and anatomic
limitations that adversely affect or limit treatment outcomes. From there, a new
classification system for alveolar ridge defects specific to esthetic implant
therapy is presented; each of these defects is subsequently correlated with
appropriate treatment options later in the book. Surgical instrumentation,
criteria for optimal flap designs, general soft tissue management
considerations, guidelines for the use of surgical maneuvers, and surgical
techniques for management of peri-implant soft tissues in specific case types
are all presented in detail. In addition, the rationale and indications for use
of periodontal soft tissue grafting techniques are provided, with details of
surgical technique as well as guidelines for peri-operative patient care.
Two innovative techniques are presented in separate sections. The impetus for
the development of the Bio-Col alveolar ridge preservation technique is
explained, along with expanded clinical applications and long-term clinical
results. The vascularized periosteal-connective tissue flap (VIP-CT flap), which
enables predictable hard and soft tissue site development of anterior maxillary
implant sites, also is presented, including the rationale, anatomic
considerations, and a summary of my clinical experience in using it.
The final section of this book presents a comprehensive approach to esthetic
implant therapy and depends to some degree on the reader’s understanding of the
sections preceding it. Following a philosophy of care for the esthetic implant
patient, hard and soft tissue implant site-development techniques are presented
in correlation with the classification system for alveolar ridge defects
introduced earlier. Prosthetic and surgical considerations for enhancing
outcomes in esthetic implant therapy, such as the use of custom healing
abutments, laser soft tissue sculpting and resurfacing, and platelet-rich
plasma, are then described. Finally, a conceptual framework for esthetic implant
site development is presented to give the implant surgeon an understanding of
the sequence and timing of procedures. The treatment algorithms included in the
Appendix help the reader navigate the challenges of treatment planning esthetic
implant therapy in an abbreviated and easy to follow format.
The many clinical cases presented throughout the book demonstrate surgical
detail in specific scenarios and can be used as a reference for the implant
surgeon treating cases with similar history, anatomic presentation, and patient
types. It is my sincere hope that the information in this book will help
clinicians master new esthetic techniques that will ultimately benefit their
patients.
Anthony G. Sclar, DMD
Private Practice
Miami, Florida
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