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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

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

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.



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