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Caton JG, Armitage G, Berglundh T A new classification scheme for periodontal and periimplant diseases and conditions - Introduction and key changes from the 1999 classification. J Periodontol. 2018; 89:(Suppl 1)S1-S8 https://doi.org/10.1002/JPER.18-0157
Renvert S, Persson GR, Pirih FQ, Camargo PM Peri-implant health, peri-implant mucositis, and peri-implantitis: case definitions and diagnostic considerations. J Periodontol. 2018; 89:(Suppl 1)S304-S312 https://doi.org/10.1002/JPER.17-0588
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An apically positioned flap and free gingival graft around an implant Matthew K Morris Debora Matthews Richard Bengt Price Dental Update 2024 51:7, 707-709.
Following the ‘2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions,’ hard and soft tissue deficiencies have been debated in the literature with keratinized mucosa at the forefront. In this case report, the present author investigated whether an apically positioned flap and free gingival graft to increase keratinized mucosa and vestibular depth improved oral hygiene and patient comfort around an implant-retained upper complete denture. Using an apically positioned flap in combination with free gingival graft to augment the soft tissues around implants with hard and soft tissue deficiencies, increased both the keratinized mucosa and vestibular depth to correct the soft tissue deficiencies. This case report highlights the importance keratinized mucosa and vestibular depth has at the patient and site level in improving oral hygiene and patient comfort. This case report also supports the growing evidence that the ideal periodontal phenotype around implants is to have keratinized mucosa ≥2 mm and vestibular depth ≥4 mm.
CPD/Clinical Relevance:
This case report supports growing evidence that the ideal periodontal phenotype around implants is to have keratinized mucosa ≥2 mm and vestibular depth ≥4 mm.
Article
Following the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions, peri-implant health, disease, conditions and deformities were reviewed.1 It has been reported that following tooth loss, hard and soft tissue deficiencies occur as result of normal healing of the alveolar ridge/process.2 This can compromise the aesthetics and long-term survival of implants, especially as maintenance is compromised. Biofilm on implant surfaces was reported as the main aetiological factor that causes peri-implant mucositis and peri-implantitis.3 Therefore, ensuring the environment is conducive, ensuring optimal oral hygiene (OH) is of utmost importance during implant maintenance for both the patient and clinician. It has been reported that patient brushing discomfort, biofilm accumulation and peri-implant soft tissue inflammation are all increased when the keratinized mucosa (KM) is <2 mm.4,5 The free gingival graft (FGG) is usually an autogenous graft harvested from the palate or tuberosity to increase KM, increase vestibular depth (VD), increase tissue thickness, treat recession, prevent further recession and improve plaque control because tissues are more resistant to physical, chemical and thermal trauma.6
This case report outlines the importance of the apically positioned flap (APF) in combination with a FGG to help improve oral hygiene around an implant-retained upper complete denture in a patient with hard and soft tissue deficiencies, who presented with poor biofilm control owing to a lack of KM and VD.
Procedure
Following informed consent, a periodontal examination was completed as defined by the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.1 The clinical assessment included the following parameters and was completed by a final-year periodontics resident, and verified by a periodontist:
Probing depths (PD) were completed in millimetres using a Williams probe.
Mucosal recession (MR) was completed in millimetres using a Williams probe.
Plaque/biofilm index (PI) was completed and scored as present or absent.
Bleeding on probing (BOP) was completed and scored as present or absent.
KM around dental implants was measured from the free mucosal margin to the mucogingival junction in millimetres using a Williams probe.
VD was completed under retraction from the deepest concavity in the muco-buccal fold to the mucosal margin in millimetres using a Williams probe. Whereby a shallow VD was <4 mm and recorded as (−) and a normal/deep VD was ≥4 mm (+).7
The patient
The patient, who 79 years of age, was medically fit and well, took no medications and had a blood pressure of 120/85 mmHg and a heart rate of 50 bpm. The patient's chief complaint was regarding the inability to clean effectively around the implant (in quadrant 1) because of the discomfort while brushing. The implants had been placed over a decade previously and the bone levels had not changed from the previous year. On presentation, the UR7 implant was more buccally placed, with a buccal dehiscence, but it was non-mobile, had shallow PDs, BOP and poor biofilm control. The BOP had not improved following oral hygiene instruction (OHI) and professional mechanical plaque removal (PMPR) at these sites over multiple visits over the year. The UR7 implant was diagnosed with peri-implant mucositis owing to hard and soft tissue deficiencies (Figures 1 and 2).
Figure 1. Orthopantomograph of patient.Figure 2. Natural smile of patient.
Surgical procedure
An apically positioned flap in combination with a free gingival graft (APF + FGG) was performed.
The bridge was removed by the prosthodontist and a pre-operative rinse was completed with 0.12% chlorhexidine glucuronate (CHX) solution (Figure 3). The FGG procedure was completed by the periodontics resident at the UR7 implant site and profound anaesthesia was achieved using two carpules of 1:200,000 articaine. A periodontist checked all parts of the procedure outlined.
Figure 3. Pre-operative photograph of the UR7 implant.
A split thickness flap at this site was completed using a no. 15 scalpel blade and periosteal elevator to expose the underlying bone (Figure 4). Saline on a dampened gauze was placed on the underlying bone during the graft harvesting process. A graft, of 1.5 mm thickness, was harvested from the right palate.
Figure 4. Apically positioned flap at the UR7 implant site.
Haemostasis at the site was achieved with oxidized regenerated cellulose (Surgicel, Ethicon, Switzerland) and cyanoacrylate adhesive dressing (Periacryl, GluStitch Inc, Canada) (Figure 5). The FGG was stabilized with 5-0 chromic gut sutures, that included one compressive suture and two simple interrupted sutures (Figure 6).
Figure 5. Haemostasis achieved on the right palate with oxidized regenerated cellulose (Surgicel) and cyanoacrylate adhesive dressing (Periacryl).Figure 6. Stabilized FGG at the UR7 implant site.
Post-operative instructions were given that included analgesia advice and the temporary interruption in brushing, while CHX was prescribed twice daily around the grafted site.
The prosthdontist replaced the bridge, and the bridge was not in contact with the donor or the UR7 recipient site prior to the post-operative appointments
Outcome
Following the APF + FGG surgical treatment at the UR7 implant site, the clinical parameters were noted and are summarized in Table 1.
Treatment
Pre-APF + FGG
Post-APF + FGG
PD (mm)
3
3
Mid-buccal MR (mm)
4
3
PI
+
–
BOP
+
–
KM (mm)
0
2
VD (±)
–
+
The increase in VD and KM gave the patient improved comfort during brushing and better access for brushing. This was represented in improved PI and BOP scores because KM and VD had increased (Figure 7).
Figure 7. Post-operative photograph of the UR7 implant site to show the increase in KM and VD.
Discussion
Although this is a single case involving one implant at the UR7 implant site, peri-implant health was achieved when corrections were made to the soft tissue deficiencies. When an APF + FGG was placed at the UR7 implant site, the increase in KM and VD improved the access for OH, especially toothbrushing. A lack of buccal bone at the coronal part of the UR7 implant site was evident when the flap was raised as shown in Figure 4. As the implant presented outside the bony housing, hard tissue regeneration was not possible and thus, only soft tissue augmentation was possible. Following the procedure, improved comfort was reported by the patient owing to the KM offering additional resistance to brushing and VD for space. At the site level, better visibility around the prosthesis was achieved following the APF + FGG and the site accumulated less biofilm (Figure 8).
Figure 8. Post-operatively, the patient had access and could angle the toothbrush appropriately for brushing, and thus maintain oral health following an increase in VD.
There is much debate in the literature about the importance of KM around implants, and this case study was completed to highlight a potential reason. Owing to few studies on this topic, the consensus has been based on predominantly animal studies and healthy peri-implant mucosa that averaged 3–4 mm in height that was either keratinized or non-keratinized.1 However, the VD is often not reported and in the few cases where it is, such as in Monje et al4 and Halperin-Sternfeld et al,8 the importance of VD is highlighted. Halperin-Sternfeld et al noted that a shallow VD was associated with greater mucosal recession around implants, increased peri-implant bone loss and narrower KM compared to when VD is ≥4 mm.8 In addition, a recent publication from Tavelli et al concluded that the APF + FGG was the most effective way to increase KM, decrease PI, and decrease PD.9 When KM was <2 mm, this type of peri-implant phenotype in patients who were erratic maintenance compliers, had more peri-implant diseases.10
Conclusion
Access to peri-implant soft tissues for OH and patient comfort during the process is important for maintaining peri-implant health. Improving KM and VD can play an important synergistic role in restoring and maintaining peri-implant health. Correcting soft tissue deficiencies is important to ensure peri-implant health. The findings in this case report support that peri-implant soft tissue deficiencies when no KM is present and VD is <4 mm, can decrease patient comfort and lead to poor OH.
Therefore, this case report supports growing evidence that the ideal periodontal phenotype around implants is to have KM ≥2 mm and VD ≥4 mm.
Future research on this matter to conclude whether VD in the absence of KM can maintain optimal OH would be beneficial to confirm the role VD has in treating soft tissue deficiencies and maintaining peri-implant health.
