rebuilding buccal plate deficiency during immediate ... · allow an immediate implant placement...

The Journal of Implant & Advanced Clinical Dentistry

Volume 10, No. 3 April 2018

Rebuilding Buccal Plate Deficiency During Immediate Implant Placement

The Bernotti V-Y Flap

ATTENTION PROSPECTIVE

AUTHORSJIACD wants to publish

your article!


For complete details regarding publication in JIACD,

please refer to our author guidelines at the following link:

jiacd.com/author-guidelines or email us at:

[email protected]

The Best Things in Life Are FREE!

Subscribe now to enjoy articles free of charge that will benefit you, the actively practicing dental provider. With each JIACD issue, readers are afforded the opportunity to

assess clinical techniques, cases, literature reviews, and expert commentary that can immediately impact their daily dental practice.

Email notification when new issues are available online.

Start your FREE subscription today at www.jiacd.com


Volume 8, No. 8 December 2016

Full Mouth Rehabilitation of Periodontitis Patient

Implant-Supported Milled Bar

Overdenture


Volume 8, No. 1 march 2016

Treatment of the Atrophic Maxilla with Autogenous Blocks

Modified Mandibular Implant Bar Overdenture


Volume 8, No. 3 may/JuNe 2016

Treatment of Mandibular Central Giant Cell Granuloma

Titanium Mesh Ridge Augmentation for Dental

Implant Placement


Volume 8, No. 4 July/August 2016

Mandibular Overdentures with Mini-Implants

Augmentation of Severe Ridge Defect with rhBMP-2

and Titanium Mesh

The Journal of Implant & Advanced Clinical DentistryVolume 10, No. 3 • April 2018

Table of Contents

6 A New Technique for Rebuilding the Buccal Plate during Placement of Immediate Dental Implants in an Extraction Site with Buccal Defects Héctor N. Norero, Mauricio A. Ibanez

16 The Bernotti V-Y Flap: An Alternative to Manage Soft Tissue Esthetic Issues with Implants Ana Luisa Bernotti, Gregori M. Kurtzman

2 • Vol. 10, No. 3 • April 2018

The Journal of Implant & Advanced Clinical Dentistry • 3


Table of Contents

28 Soft Tissue Augmentation to Increase Width of Keratinized Tissue Around Dental Implants Using Tissue Fixation Screws: A Novel Technique for Graft Tissue Stabilization Dr. Lank Mahesh, Dr. Nitika Poonia, Dr. Vishal Gupta

34 The Waya Technique: A Novel Approach Using a Palatal Flap of Apical Repositioning for Primary Tension-Free Closure in Maxillary Bone Augmentation Britto Falcón-Guerrero


PublisherLC Publications

DesignJimmydog Design Group www.jimmydog.com

Production ManagerStephanie Belcher 336-201-7475 • [email protected]

Copy EditorJIACD staff

Digital ConversionJIACD staff

Internet ManagementInfoSwell Media

Subscription Information: Annual rates as follows: Non-qualified individual: $99(USD) Institutional: $99(USD). For more information regarding subscriptions, contact [email protected] or 1-888-923-0002.

Advertising Policy: All advertisements appearing in the Journal of Implant and Advanced Clinical Dentistry (JIACD) must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. The publication of an advertisement in JIACD does not constitute an endorsement by the publisher. Additionally, the publisher does not guarantee or warrant any claims made by JIACD advertisers.

For advertising information, please contact:[email protected] or 1-888-923-0002

Manuscript Submission: JIACD publishing guidelines can be found at http://www.jiacd.com/author-guidelines or by calling 1-888-923-0002.

Copyright © 2018 by LC Publications. All rights reserved under United States and International Copyright Conventions. No part of this journal may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying or any other information retrieval system, without prior written permission from the publisher.

Disclaimer: Reading an article in JIACD does not qualify the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD readers should exercise judgment according to their educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its staff, and parent company LC Publications (hereinafter referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.

Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD-SOM. JIACD-SOM disclaims any responsibility or liability for such material and does not guarantee, warrant, nor endorse any product, procedure, or technique discussed in JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims made by manufact-urers of products advertised in JIACD, its affiliated websites, or affiliated communications.

Conflicts of Interest: Authors submitting articles to JIACD must declare, in writing, any potential conflicts of interest, monetary or otherwise, that may exist with the article. Failure to submit a conflict of interest declaration will result in suspension of manuscript peer review.

Erratum: Please notify JIACD of article discrepancies or errors by contacting [email protected]

JIACD (ISSN 1947-5284) is published on a monthly basis by LC Publications, Las Vegas, Nevada, USA.

4 • Vol. 10, No. 3 • April 2018


Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

Michele Ravenel, DMD, MSTerry Rees, DDSLaurence Rifkin, DDSGeorgios E. Romanos, DDS, PhDPaul Rosen, DMD, MSJoel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDHenry Salama, DMDMaurice Salama, DMDAnthony Sclar, DMDFrank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDSMichael Sonick, DMDAhmad Soolari, DMDNeil L. Starr, DDSEric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDSEmil Verban, DDSHom-Lay Wang, DDS, PhDBenjamin O. Watkins, III, DDSAlan Winter, DDSGlenn Wolfinger, DDSRichard K. Yoon, DDS

Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

Co-Editor in ChiefLeon Chen, DMD, MS, DICOI, DADIA


Norero et al

The final decision when placing a den-tal implant in an extraction site must be done looking at the integrity of the

socket walls. When the buccal plate is par-tially or totally lost, the primary treatment goal is to preserve the socket until it matures for good implant stability and good esthetic results. What this technique proposes is to allow an immediate implant placement without the problems, esthetic and functional issues of the future final restoration. Platelet rich fibrin mixed with allogeneic mineral bone is rich in

leucocytes and it is the best way to avoid com-plications when placing immediate implants.

This L-PRF produces a dense and rich fibrin matrix containing five of the most important growth factors involved in bone and soft tissue healing. This mix of autologous fibrin glue and allogeneic mineral bone provides the stabili-zation of the bone graft in that gap, improving the primer stability of the implant in the extrac-tion site. This report presents the step-by-step technique to obtain a successful result in the immediate implantation of the dental implant.

A New Technique for Rebuilding the Buccal Plate during Placement of Immediate Dental Implants

in an Extraction Site with Buccal Defects

Héctor N. Norero, DDS1 • Mauricio A. Ibanez , DDS2

1. Periodontist, Universidad de Chile. Private Practice, Santiago, Chile

2. Periodontist, Universidad Diego Portales. Private Practice, Santiago, Chile

Abstract

KEY WORDS: Dental implant, immediate dental implant, platelet rich fibrin, bone graft

6 • Vol. 10, No. 3 • April 2018

Norero et al


BACKGROUNDSeveral studies have shown that the results obtained when placing implants in a fresh sock-ets are greater than to preserve the site and delay installation of the implant. This would cause greater difficulty for the correct placement of the implant with aesthetic consequences for the patient.1,2 In the last 10 years, the installation of dental implants in fresh post-extraction sockets has demonstrated that there are numerous factors involved in the aesthetic success of a dental implant and the maintenance of the parame-ters that show us the stability of the biological complex around the implant. The position of the gingiva and stability of the bone level, the rela-tionship of proximity to the neighboring teeth, the loads of the opposing dentition to which the prosthesis is subjected to, and position of the implant- abutment interface.3,4 Within the most challenging problems, it is difficult to determine the thickness and the indemnity or not of the ves-tibular bone plate.5 We must be careful with the selection of the diameter of the implant in rela-tion to the diameter of the socket where it is to be inserted and how the gap fill will heal and the bone plate when it is partially or totally lost.6

There have been numerous attempts to recon-struct the vestibular plate,7 using a bone graft from the tuberosity repairing the bone defect, with the complications that arise from taking the graft and then positioning it. Another way is to keep part of the vestibular root without extract-ing it, in order to keep the bone contour with the implant more palatine. This is achieved only with skill from the operator and not exempt of early or late complications of the piece of root that remains in the socket.8 The use of platelet rich fibrin (L-PRF)9,10,11 to obtain a gel-like mixture

with the filling material used, and placed in the gap left by the implant and the vestibular socket, prior to placing the implant, allows one to create a new buccal wall, and a wider surface that will be in contact with the implant and will not put pressure on the remaining vestibular plate. This allows for very good stability of the implant and a healing accelerated by the contribution of cyto-kines and growth factors that come from the gel installed in the gap of autologous origin.12,13,14 The way that we propose to protect the bone plate and fill the gap is easy to perform does not require specialized instruments, and is inex-pensive. For the past four years, using this technique we have seen positive results in all aesthetic parameters where it has been used with dental implants. In this paper, we will show the technique step by step so that any clinician in their daily work can reproduce it.

CLINICAL PROTOCOL l Patients healthy or with controlled general

diseasel Patients with or without history of periodontal

disease with control of plaque less than 20% of covered surfaces

l Patient is a candidate for immediate replace-ment of tooth extraction by an implant

l Surgery without flapl Debridement of the epithelial insert

with blunt instrumentl Extraction atraumatic as possible with

a periotome or luxatorl Checking the anatomy of the remaining socket15

l Preparing the bed that will receive the implant l Process collected blood to obtain L-PRF

(3 tubes) for 12 minutes at 2700 rpm16

Norero et al

8 • Vol. 10, No. 3 • April 2018

l Remove the supernatant from each tube in a sterile 10ml syringe and preserve

l Remove from the tube the fibrin clot obtained and particulate it, within a glass cup and inte-grate with the bone filling, to be used in this case Puros® ,mineral small cortical particles17

l Positioning inside the prepared bed for the installation of the implant, the last bur used

l Begin to fill with the fibrin gel that includes bone filling, the space between the bur and the internal wall of the gingival tissue, mold-ing gently and compacting it apically

l Space must be filled to the free edge of the gingiva

l After this, with the supernatant from each tube collected, put some drops on the already stable filling causing greater stiffness in the filling gap

l The implant is installed to its final sub osse-ous position in the case of implants of conical connection and platform shift

l If the insertion of the implant exceeds 25 Ncm2 proceed to install the final prosthetic abutment and torque it, otherwise, it is left with a heal-ing abutment to shape the emergence profile

l The temporary crown is made without occlusal contact

l The osseointegration protocol is followed according to the implant manufacturers recommendation to go to the definitive prosthesis phase

Figure 1: Post-extraction socket with final bur in position. Figure 2: Filling the gap with L-PRF+Allograft gel form.

Norero et al


Figure 3: Final reconstruction of socket buccal plate, ready to receive the implant

Figure 4: Implant in position, showing the rebuilt buccal plate.

Figure 5: Implant with crown.

PROSTETHIC PROTOCOLl Once the osseointegration time has been

completed, the provisional crown is removedl The final impression is made with reproduction

of the emergence profilel The definitive prosthesis is madel Adjustment, aesthetic and occlusal tests

are performedl The final restoration is screw in or cemented

CLINICAL CASE SAMPLEl Patient chief complain to solve an old tooth frac-

ture (5 years of evolution) in tooth 1.1 (Photo 1)l Radiographically (CBCT) shows a fracture of

the apical third with slight vestibular displace-ment and ankylosis of the apical third (Photo 2)

l A CBCT is able to demonstrate the absence of at least half of the vestibular plate of the socket

Norero et al

10 • Vol. 10, No. 3 • April 2018

Photo 1: Pre-op view.

Photo 2: Diagnostic CBCT.

Photo 3: PRF clot.

Photo 4: Mixing with mineralized allogeneic bone.

Photo 5: L-PRF as membrane.

Norero et al


Photo 6: Gel form of the mixed bone particles and L-PRF membrane.

Photo 7: Introducing the gel prep in the vestibular defect.

Photo 8: Final adaptation of the gel prep. Photo 9: Implant placement.

l It was decided to make the extraction of 1.1 tooth, the upper two-thirds and maintain the apical third, considering the difficulties of the extraction of the apex and the possible bony destruction by an apical external approach, which would compromise the stability of the future implant

l Before the surgery, 40 cc of patient venous blood is taken in 4 tubes red cap. The blood was centrifuged for 12 minutes and 2700 rpm

l The result was 4 fibrin clot (Photo 3)

l Two of them was particulate and mixed with mineralize allogeneic bone small particles (Photo 4)

l The other two was processed to obtain 2 L-PRF membranes (Photo 5)

l First I proceed with a careful extraction of tooth 1.1

l The preparation of the surgical bed is located in a more palatal position of the socket

l The gap was filled with Sticky bone prior to implant placement (Photos 6-7)

Norero et al

12 • Vol. 10, No. 3 • April 2018

Photo 12: View of the temporal crown at four month.

Photo 13: Control CBCT at 4 month post-opt.

Photo 10: Implant in is final position, covering the graft with L-PRF membrane form.

Photo 11: Healing abutment in position.

l The implant was putting in the previous preparation (Photos 8- 9)

l The stability of the implant was less than 25 Ncm2, so it was left only with a healing abutment (Photo 10)

l Besides of the healing abutment was placed two L-PRF in membranes form, covering the graft (Photo 11)

l The crown of the extracted tooth was used as temporary using adhesion to the neighboring teeth (Photo 12)

Norero et al


Photo 14: Emergency profile at four month after retrieval of the healing abutment.

Photo 15: Probing the Titanium base for CAD-CAM rehabilitation.

Photo 16: Try in of CAD-CAM Zi structure. Photo 17: Final CAD-CAM restoration.

l At four month a CBCT was taken (Photo 13)l After retrieval of the healing abutment

(Photo 14), we proceed to take an impres-sion coping the emergence profile and the dental laboratories did the stone model.

l This model was scanned optically and designed the crown in the software Cerec4.5

l The crown was printed and after that was cemented outside the mouth to obtain the final screw restoration (Photos 15, 16)

l The crown was screwed in position (Photo 17)

CLINICAL EVALUATIONl Both bone and soft tissue healing performed

without complications l The regenerated site healed well and was

evaluated after a 2 years at this timel A CBCT was taken at four months before

the final restoration was placedl A formation of a vestibular wall with a bony fill-

ing of the socket with normal characteristicsl The final crown was did by CAD-CAM

Cerec® (Dentsply Sirona)

Norero et al

14 • Vol. 10, No. 3 • April 2018

Correspondence:Dr. Héctor N. Norero,Fax: 56-222338594e-mail: [email protected]

DISCUSSIONThe increased use of dental implants in the last 20 years has brought to light the appearance of bony defects produced by deficient bone at the time of implant surgery, poor implant place-ment or poor operator experience that have underestimated the implant and lack of pre-installation analysis. Bony defects increase gin-gival irritation, poor healing with aesthetic and functional consequences, which are very dif-ficult to reverse once the implant has already osseointegrated and rehabilitated.18 Immedi-ate placement of implants after dental extrac-tion represents many advantages for the patient and the treating Dentist, like shorter appoint-ments and faster healing of the soft tissues that is enhanced by the use of the membranes of L-PRF and the mixed with the bone fillers who has an important roll in the hard tissue heal-ing.19,20 Numerous publications have addressed this issue in different ways to totally or partially restore the defect with different success rates and with high difficulty and reproducibility. But the advantage of using a highly compact filler and healing with autologous accelerators for the support of the soft tissue is improving.21 Such techniques make the presence of the contours of the osseous tissue more predict-able.22 All of the above is relevant in areas of high aesthetic demand especially in single tooth replacements where the similarity of nearby sites should be maintained or replicated.

The first open protocol shown by Chouk-roun and Dohan to produce L-PRF, using cen-trifugation speed 2700 rpm for 12 minutes,23 is the best way to obtain a very resistant L-PRF membrane, to use alone o mixed with same mineral allogeneic graft. It is so important the

selection of the biomaterial for fill the gap, it must be, quick replace for natural bone and maintaining the space between the vestibular face of the implant and the soft tissue at least for 3 month. In our experience in according with the literature the mineralized bone, alloge-neic small particles have the best results along the life of the implant.24 The experience in this type of technique of preservation or enhanc-ing the vestibular wall partially or totally lost for already four years indicates that the bone lev-els are maintained or even improved allowing the coronary advancement of the free edge of the gingiva in up to two millimeters on average.

CONCLUSIONSThis technique leads us to think that with-out incurring in major costs we have the possibility of reconstructing the vestibu-lar wall loss in areas of high esthetic demand with predictable and reproduc-ible results after the extraction of the tooth.

The use of the technique for 4 years in more than 60 cases show that it clinically behaves in a stable manner. Another advan-tage observed is that the insertion torque of the implant is increased at least by 20% making it more feasible for the implant to be loaded immediately in a greater number of times. The following 3-year research will give us insight into its long-term stability. l

Norero et al


Product IdentificationAnkylos® Dental implant system and Cerec® system(Dentsply Sirona, Delaware, 221 W.Philadelphia Street York,PA 17405-0872.E.E.U.U.).Puros®mineralized bone allograft particulate (Zimmer-Biomet dental, Palm Beach Gardens, Florida 33410).

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

Special thanksMs. Daniela Diaz, for the artwork.Ms. Paulina Nunez. Dental technician

References1. Gapski R, Wang H-L, Mascarenhas P, Lang NP.

Critical review of immediate implant loading. Clin. Oral Impl. Res, 14, 2003; 515–527

2. Akiyoshi Funato, Maurice Salama, Tomohiro Ishikawa, David Garber, Henry Salama. Timing, Positioning, and Sequential Staging in Esthetic Implant Therapy:A Four-Dimensional Perspective. Int J Periodontics Restorative Dent 2007; 27: 313-323.

3. Hugo de Bruyn, Stefanie Raes, Pär-Olov Östman, Jan Cosyn.Immediate loading in partially and completely edentulous jaws: a review of the literature with clinical guidelines,Periodontology 2000,vol 66, issue 1, October 2014,153-187.

4. Catinari M, Scimeca M, Amorosino M, Marini M, Bonanno E, Tancredi V. Mandibular regeneration after immediate load dental implant in a periodontitis patient: A clinical and ultrastructural case report. Zheng. LW, ed. Medicine. 2017;96(15):e6600.

5. Spinato S., Galindo-Moreno P.,Zaffe D.,Bernardello F.,Soardi CM..Is socket healing conditioned by buccal plate thickness? A clinical and histologic study 4 months after mineralized human bone allografting. Clin. Oral Impl. Res. 25 ,2014, e120–e126

6. Kan JY, Roe P, Rungcharassaeng K. Effects of implant morphology on rotational stability during immediate implant placement in the esthetic zone.Int J Oral Maxillofac implants, 2015 May-Jun;30(3):667-70. doi: 10.11607/jomi.3885.

7. José Carlos Martins Da Rosa. Restauración Dentoalveolar Inmediata..1th ed. Ed. Santos 2012.

8. Gharpure AS, Bhatavadekar NB. Current Evidence on the Socket-Shield Technique: A Systematic Review. J Oral Implantol., Aug 2017

9. Shahram Ghanaati, Patrick Booms, Anna Orlowska, Alica Kubesch, Jonas Lorenz, Jim Rutkowski, Constantin Landes, Robert Sader, CJ Kirkpatrick, Joseph Choukroun, Advanced Platelet-Rich Fibrin: A New Concept for Cell-Based Tissue Engineering by Means of Inflammatory Cells, Journal of Oral Implantology. 2014;40(6):679-689.

10. Choukroun J. Et al .Injectable Platelet rich fibrin: a Smart blood concentrates J.Cell Communication Signaline .2016

11. David M. Dohan Ehrenfest, Giuseppe M. de Peppo, Pierre Doglioli & Gilberto Sammartino. Slow release of growth factors and thrombospondin-1 in Choukroun’s platelet-rich fibrin (PRF): a gold standard to achieve for all surgical platelet concentrates technologies. Pages 63-69 | Received 10 Sep 2008, Accepted 20 Nov 2008, Published online: 11 Jul 2009

12. David M. Dohan E. Tomasz Bielecki ,Ryo Jimbo, Giovanni Barbé , Marco del Corso,Francesco Inchingolo and Gilberto Sammartino. Do the Fibrin Architecture and Leukocyte Content Influence the Growth Factor Release of Platelet Concentrates? An Evidence-based Answer Com- paring a Pure Platelet-Rich Plasma (P-PRP) Gel and a Leukocyte- and Platelet-Rich Fibrin (L-PRF) Current Pharmaceutical Biotechnology, 2012, 13, 1145-1152

13. Dohan Ehrenfest DM .How to optimize the preparation of leukocyte- and platelet-rich fibrin (L-PRF, Choukroun’s technique) clots and membranes: introducing the PRF Box. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Sep; 110(3):275-8; author reply 278-80.

14. Dong-Seok Sohn, Bingzhen Huang, Jin Kim, W. Eric Park, Charles C. Park, Utilization of Autologous Concentrated Growth Factors (CGF) Enriched Bone Graft Matrix (Sticky Bone) and CGF-Enriched Fibrin Membrane in Implant Dentistry. The Journal of Implant & Advanced Clinical Dentistry, Volume 7, No . 10 • December 2015; 11-30

15. Elian N, Cho SC, Froum S, Smith RB, Tarnow DP. A simplified socket classification and repair technique. Pract Proced Aesthet Dent, 2007,Mar;19(2):99-104.

16. David M. Dohan, et al The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors and fibrin architecture of a Leukocyte- and Platelet-Rich Fibrin (L-PRF) clot and membrane. Part 1: evaluation of the vibration shocks of 4 models of table centrifuges for L-PRF. POSEIDO.2014;2(2);129-39

17. Noumbissi SS, Lozada JL, Boyne PJ, et al. Clinical, histologic, and histomorphometric evaluation of mineralized solvent-dehydrated bone allograft (Puros) in human maxillary sinus grafts. J Oral Implantol. 2005;31:171-179.

18. Hsu YT, Mason SA, Wang HL. Biological implant complications and their management. J Int Acad Periodontol .2004 Jan 16(1) 9-18.

19. A David C. Greenspan, Ph.D. Physical And Chemical Properties Of Commercially Available Mineralized Bone Allograft. Copyright 2012 by Zimmer Dental Inc.

20. M. Marrelli, M. Tatullo. Influence of PRF in the healing of bone and gingival tissues. Clinical and histological evaluations. European Review for Medical and Pharmacological Sciences. 2013; 17: 1958-1962

21. Su CY, Kuo YP, Tseng YH, Su CH, Burnouf T. In vitro release of growth factors from platelet-rich fibrin (PRF): a proposal to optimize the clinical applications of PRF. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Jul;108(1):56-61

22. Dong-Seok Sohn, Bingzhen Huang, Jin Kim, W. Eric Park, Charles C. Park, Utilization of Autologous Concentrated Growth Factors (CGF) Enriched Bone Graft Matrix (Sticky Bone) and CGF-Enriched Fibrin Membrane in Implant Dentistry. The Journal of Implant & Advanced Clinical Dentistry, Volume 7, No . 10 • December 2015; 11-30

23. Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, Dohan AJ, Mouhyi J, Dohan DM, Platelet-rich fibrin (PRF) Second-generation platelet concentrate .Part IV: clinical effects on tissue healing.Oral Surg Oral Med Oran Pathol Oral Radiol Endod.2006,101(3):e56-60

24. Collins, James Rudolph DDS*; Jiménez, Ely DDS†; Martínez, Carol DDS†; Polanco, Rubén Tobias DDS‡; Hirata, Ronaldo DDS, MS, PhD§; Mousa, Ramy MS‖; Coelho, Paulo G. DDS, MS, BS, MSMtE, PhD¶; Bonfante, Estevam A. DDS, MS, PhD#; Tovar, Nick PhD** .Clinical and Histological Evaluation of Socket Grafting Using Different Types of Bone Substitute in Adult Patients. Implant Dentistry: August 2014 - Volume 23 - Issue 4 - p 489–495.

Norero et al

Bernotti et al

Mucosal issues such as inflammation, swelling, fistulas, lack of sufficient kera-tinized tissue, deficient buccal contour

volume, recession and thin biotype became treat-ment challenges with implant and natural tooth restorations, especially when less than ideal 3D position implant placement has resulted. Man-agement of the soft tissue with an inadequate flap incision may complicate surgical results instead of improving the clinical situation, leading to api-cal mucosal recession and the resulting aesthetic complications that may ensue. This may lead treat-ment toward explantation of the implant, grafting and new implant placement to correct the clinical issues that warranted correction treatment. The “Bernotti V-Y Flap” eliminates the complications reported with other approaches to correct these clinical issues. It is a predictable minimal coro-

nally advanced flap for root coverage when iso-lated recession is present and biotype mucosal improvement is sought. The Bernotti V-Y Flap may be combined with or without connective tissue grafting, PRF membranes or decellularized human dermal tissue (freeze-dried or dehydrated allograft tissue) at natural tooth or implants sites. This tech-nique eliminates the need for vertical incisions that could compromise the blood supply and the mar-ginal surrounding bone, preserving the papillae. Additionally, the technique allows tissue prosthetic guidance for the maintenance and improvement of the vestibular aesthetic area of the site being treated. A case describing soft tissue biotype and aesthetic improvement of a malpositioned implant that had been previously restored with the Ber-notti V-Y flap will be discussed as an example what can be accomplished with this technique.

The Bernotti V-Y Flap: An Alternative to Manage Soft Tissue Esthetic Issues with Implants

Ana Luisa Bernotti, DDS1 • Gregori M. Kurtzman, DDS, MAGD, DICOI2

1. Private practice, Caracas, Venezuela

2. Private practice, Silver Spring, Maryland, USA

Abstract

KEY WORDS: Dental implants, mucogingival graft, soft tissue defect

16 • Vol. 10, No. 3 • April 2018

Bernotti et al


INTRODUCTION Mucosal issues such as inflammation, swelling, fistulas, lack of sufficient keratinized tissue, defi-cient buccal contour volume, recession and thin biotype became treatment challenges with implant and natural tooth restorations, especially when less than ideal 3D position implant placement has resulted. Management of the soft tissue with an inadequate flap incision may complicate surgi-cal results instead of improving the clinical situa-tion, leading to apical mucosal recession and the resulting aesthetic complications that may ensue. This may lead treatment toward explantation of the implant, grafting and new implant placement to correct the clinical issues that warranted cor-rection treatment. The “Bernotti V-Y Flap” elimi-nates the complications reported with other approaches to correct these clinical issues. It is a predictable minimal coronally advanced flap for root coverage when isolated recession is present and biotype mucosal improvement is sought. The

Bernotti V-Y Flap may be combined with or with-out connective tissue grafting, PRF membranes or decellularized human dermal tissue (freeze-dried or dehydrated allograft tissue) at natural tooth or implants sites. This technique eliminates the need for vertical incisions that could compro-mise the blood supply and the marginal surround-ing bone, preserving the papillae. Additionally, the technique allows tissue prosthetic guidance for the maintenance and improvement of the ves-tibular aesthetic area of the site being treated. A case describing soft tissue biotype and aes-thetic improvement of a malpositioned implant that had been previously restored with the Ber-notti V-Y flap will be discussed as an example what can be accomplished with this technique.

THE BERNOTTI V-Y FLAP Isolated mucosal recession Miller Class I reces-sion can be challenging to treat with predictable results, especially in the aesthetic zone. Periodon-

Figure 1: A “V” incision is made with the scalpel apical to the mucosal recession, extended to the mucogingival junction while sparing the papilla by 4mm on each side.

Figure 2: Total Thickness flap is elevated toward the coronal and scaling and topic antibiotic application is used to decontaminate the exposed implant surface, which is followed by a water rinse.

Bernotti et al

18 • Vol. 10, No. 3 • April 2018

Figure 3: The connective tissue graft taken from tuberosity, which has the epithelial layer removed is placed under the flap and suture to the interior of the flap, using an interrupted suture technique.

Figure 4: The flap is repositioned over the underlying connective tissue graft.

Bernotti et al


Figure 5: Tissue above the “V” flap is approximated and sutured using horizontal mattress sutures utilizing 6-0 monofilament Polypropylene.

Figure 6: The technique derives its name from the “V” incision initially placed (left) and the resulting “Y” closure (right) to correct the single tooth recession.

Bernotti et al

20 • Vol. 10, No. 3 • April 2018

tal Plastic Surgery (PPS), was first suggested by Miller (1988), defined as surgical proce-dures performed to prevent or correct anatomi-cal, development, traumatic or plaque disease, induced defects of the gingiva, alveolar mucosa, or bone. (The American Academy of Periodon-tology 1996) Periodontal plastic surgery will improve aesthetics, blending soft tissue color and texture of the implant area with the adja-cent soft tissues (De Sanctis & Zucchelli 2007), while improving mucosa biotype to a thicker bio-type and increasing keratinized mucosa band.

The Bernotti V-Y flap technique alone or in combination with soft tissue grafting, PRF membranes or Decellularized Human Dermal Tissue (freeze-dried or dehydrated allograft tis-sue) at natural tooth or implant sites may be indicated when thin mucosa biotype and/or isolated gingival recessions are present, kera-tinized tissue gain is needed and soft tissue aesthetic results require improvement. This technique allows protecting and maintaining the stability of subjacent peri- implant bone.

The Bernotti V-Y flap periodontal plastic approach, is a coronally advanced flap modifica-

tion, inspired by Tarnow’s Semilunar Flap and V-Y frenillectomy. It is a simple technique to treat isolated mucosal recession. The technique con-sists of a pedicle flap, a ¨V ¨incision, without lose of flap blood supply and suturing with a horizon-tal mattress technique the vertical slope making a ¨Y¨ design while pushing or advancing the flap coronally to cover the mucosal recession with-out tension to the pedicle flap. The apical por-

Figure 7: Resulting esthetics presents with a lateral incisor that is longer then the adjacent teeth as the patient’s chief complaint.

Figure 8: Lateral view of the facial soft tissue demonstrating thin tissue with a pin point perforation 3mm below the mucosal margin.

Bernotti et al


Figure 9: Periapical radiograph as patient presented demonstrating crestal defect present when implant had been placed by prior practitioner with Bicon® implant (3,5mm∅, 11mm long) positioned supracrestally. Vestibular placement (Bicon® implants are always placed subcretally ).

Figure 10: The single piece restoration with porcelain fused to the morse taper Bicon abutment.

Figure 11: The implant restoration was removed revealing moderate inflammation at the mucosal cuff.

tion of the flap rests on the bone following the coronal advancement to cover the recession defect. The incision should end at least 4mm from the papilla on each inter-proximal area to be treated, but not extended to the tip of the papilla (Figure 1). To prevent papilla loss, 2 mm must be left attached on each side of the flap to pre-

Bernotti et al

22 • Vol. 10, No. 3 • April 2018

Figure 12: Inflammation is present at the thin facial tissue between the gingival margin and crestal bone creating additional esthetic issues.

Figure 13: A diamond in a high-speed handpiece is utilized to modify the emergence profile (umbrella concept: space for the tissue) of the single piece restoration and place the gingival emergence at its proper position incisal-apically.

Figure 14: The modified single piece restoration has been reinserted into the implant and the perforation in the facial gingival tissue is noted.

serve blood supply. Next, a mid-facial intrasulcu-lar incision is made, to allow coronal movement of the marginal tissue to cover the concave zone (sub-critical zone) and re-design the scalloped mucosal margin according to the lip line (smile) and the coronal zenith (Figure 2). Suturing of the connective tissue graft internally collected from the tuberosity to the “V” flap and the flap to the attached tissue (Figures 3, 4). The vertical slope is sutured with a horizontal mattress tech-nique making a ¨Y¨ design (Figure 5). The flap is advanced coronally without tension to the ped-icle flap. The soft tissue margin is placed 2 mm coronally from the CEJ of adjacent teeth. Hence

Bernotti et al


Figure 15: A connective tissue graft is harvested from the edentulous tuberosity.

Figure 16: The keratinized layer of the donor graft is removed with a scalpel blade 15c.

Figure 17: A “V” incision is made up to the mucogingival junction with a scalpel blade 15c. A mid-facial intrasulcular incision mesial to distal site preserving 2 mm of attached papilla and all the way apically to the “v” incision.

Figure 18: The full thickness flap is elevated in a coronal direction and ultrasonics utilized to remove any calculus at the coronal aspect of the implant.

Bernotti et al

24 • Vol. 10, No. 3 • April 2018

Figure 19: Conditioning of the site with a gauze impregnate with Tetracycline previous to place the donor connective tissue graft over the site and under the “V” flap.

Figure 20: The site is sutured closed using 6-0 monofilament horizontal mattress sutures from the middle of both incisions mesial and distal making a vertical slope of the “Y” pushing or moving coronally the “V” flap, keeping the flap tension free.

Figure 21: The site at 7 days at post-operative recall, demonstrating mild inflammation and thicker tissue at the site with no exposure of the underlying implant restoration.

Figure 22: Post-operative evaluation of the donor graft site at the tuberosity at 7 days demonstrating ongoing healing.

Figure 23: The surgical site at 3-month post -operatively demonstrating mild peripheral inflammation as healing progresses and thicker tissue over the site.

Bernotti et al


Figure 24: 1 year post-operative evaluation demonstrating a lack of inflammation at the site, stability of the repositioned gingival margin with improved esthetics and thicker tissue on the facial.

Figure 25: Occlusal view at 1-year post-operative demonstrating thicker tissue with a better facial volume.

the name is derived from the initial incision (“V”) and the resulting tissue closure (“Y”) (Figure 6).

The Bernotti V-Y flap technique is recom-mended when a keratinized mucosal band is present, to cover mucosal recession on teeth or implants sites. Factors such as gingival bio-type and keratinized mucosa width must be con-sidered, when performing the technique. When insufficient keratinized tissue is not present, it can be combined with soft tissue grafts, PRF membranes, Decellularized Human Dermal Tis-sue (freeze-dried or dehydrated allograft tissue).

CASE REPORT

A Caucasian 69-year-old female presented in good general health was referred to evalu-ate and treat an aesthetic issue in the maxillary anterior. The patient complaint was an aes-thetic concern, with the implant crown appear-ing longer than the adjacent teeth (Figures 7, 8). Radiographically it was noted that a narrow diameter Bicon® implant (3.5 mm x 11 mm) with associated restoration was present at the maxillary right lateral incisor (Figure 9). Dur-

ing oral examination it was noted a peri-implant mucositis lesion present at the right maxillary lateral incisor where a restored implant was present. A 4mm buccal recession defect was noted measured from the CEJ of adjacent teeth to the zenith implant-crown restoration. A fis-tula was identified with associated inflammation at the mid-facial buccal tissue of the restored implant. Suppuration from the fistula was noted. The implant had been placed and restored 3 years earlier in an unfavorable 3D position. Removal of the implant was not an option due to financial considerations (socioeconomic status) and the patient’s declination of that treatment option. Additionally, explantation in the ante-rior maxilla with the position of this particular implant could lead to a severe bone lose further complicating treatment. Following discussion with the patient on what treatment options were available it was decided to treat the site to improve the tissue health (eliminate the fistula and associated mucositis) and improve the aes-thetics utilizing the Bernotti V-Y Flap technique to allow a minimal invasive coronally reposi-

Bernotti et al

26 • Vol. 10, No. 3 • April 2018

tioned flap combined with soft tissue grafting. Prior to surgery full-mouth scaling and

root planning had been performed to improve the general periodontal health of the tis-sue. The patient was prescribed Amoxicil-lin 500 mg 3 times a day for 7 days, starting the day before surgery. Local anesthesia was administered (2% Xylocaine w/ 1: 200 000 epinephrine) to the surgical areas. The crown-abutment complex was removed from the implant. As the abutment post is friction fit-ted into the Morse taper connection in the implant, the restoration was removed from the implant with forceps (Figure 10). The mucosa surrounding the implant connec-tor demonstrated mucositis (Figures 11, 12).

The contour of the abutment/crown com-plex was modified to create a concave sub-gingival area that would lie below where the intended new position of the gingival margin would lie. This was performed using a round diamond in a high-speed handpiece to cor-rect the over-contoured convex shape of the restoration and allow the soft tissue to posi-tion more coronally (Figure 13). The “umbrella concept” (Alberto Miselli, 2016) allows space for the soft tissue of the single piece restora-tion and place the gingival emergence at its proper position incisal-apically. The restora-tion was reinserted into the implant (Figure 14).

Incisions were made in the edentulous tuber-osity with a #15c scalpel blade (SM: Swann Morton, Devemed GmbH. Germany) to col-lect donor connective tissue for the recession defect. A partial thickness piece of tissue was removed from the tuberosity (Figure 15). The connective tissue graft from the tuberosity was depithelized by scraping the exterior surface

with the edge of the #15c blade (Figure 16).A ¨V¨ incision was made with a #15c scal-

pel blade at the muco-gingival junction apical to the recession defect, from proximally 4mm from the mesial papilla, and 4 mm from the dis-tal papilla, and extended to the mid-facial region into the mucosa, converging with the first inci-sion, making a “V” full thickness flap (Figure 17). The flap was elevated with a periosteal elevator. (PPS 1100F Allen#2 17,3 cm/2mm Devemed GmbH, Germany) elevating the tissue coronally. An ultrasonic instrument (Satelec, Aceton North America, Mt Laurel, NJ) was uti-lized to clean the supracrestal portion of the implant under the elevated flap (Figure 18). The connective tissue donor graft procured from the tuberosity was placed under the flap and sutured to it, using an interrupted suture technique utilizing 6-0 monofilament Polypro-pylene Suture with a 3/8 Circle Reverse Cut-ting needle (Dolphin Sutures, Bangalore, India), covering the exposed implant connector and restorative complex (Figure 19). The “V” flap was closed. Tissue above the “V” flap was then approximated and sutured using horizon-tal mattress sutures utilizing 6-0 monofilament Polypropylene sutures 6-0 (Figure 20). The patient was dismissed and instructed to con-tinue with the antibiotics and return in 1 week to check site healing and 2 weeks post surgi-cally for suture removal. Ibuprophen (400mg) was recommended for pain management taken twice daily for the first 3 days post surgically.

One week post surgery the site appeared to have a small area of exposure of the under-lying connective tissue was noted with slight soft tissue inflammation as the recipient site (Figure 21). The donor site demonstrated cov-

Bernotti et al


erage of the tuberosity by granulation tissue and normal healing was evident (Figure 22). The patient returned at 2 weeks and sutures were removed and the patient instructed to con-tinue using warm salt water rinses a few times daily for the next week to aid in tissue healing.

Re-evaluation at 3 months’ post-surgery demonstrated mild peripheral inflammation as healing progresses and thicker tissue over the site (Figure 23). At 1 year post-operative evalu-ation the site demonstrated a lack of inflamma-tion and stability of the repositioned gingival margin with improved esthetics and thicker tis-sue on the facial (Figure 24). The overall con-tour of the facial had a more natural appearance compared to the initial presentation (Figure 25).

CONCLUSIONThe Periodontal plastic surgery coronally advanced flap using the Bernotti V-Y flap tech-nique is a minimally invasive surgery used as an alternative for isolated tissue issues at implant and tooth sites, without compromising the mar-ginal soft tissue that could lead to create aes-thetics concerns for the patient. The flap design protects the interdental tissue without expos-ing underlying bone in association with an improved blood supply to the soft tissue in the surgical site, with less potential crestal bone loss. The technique allows coronal placement of the mucosal tissue with no tensions favored for the horizontal mattress suture made at the vertical slope of the ¨Y¨ incision, to secure the stability of the coronally flap position. Alone or in combination with tissue graft, will reduce mucosal recession, gain keratinized tissue and obtain satisfactory aesthetic results main-taining margin tissue in a predictable way. l

Correspondence:Dr. Gregori [email protected]

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. Zuchelli. G; Mele. M; Mazzotti. C; Marzadori. M; Montebugnoli. L; De Sanctis. M.

(2009). Coronally Advanced Flap With and Without Vertical Releasing Incisions for the Treatment of Multiple Gingival Recessions: A Comparative ControlledRandomized Clinical Trial. Journal of Periodontology. Vol.80, No. 7, Pages 1083-1094.

2. Cordaro. L; Mirisola. V; Torsello. F. (2012). Split-Mouth Comparison of aCoronally Advanced Flap With or Without Enamel Matrix Derivative for Coverage of Multiple Gingival Recession Defects: 6- and 24-month Follow-up. TheInternational Journal of Periodontics & Restorative Dentistry, Volume 32, No 1,Pages 10-19.

3. Sunitha. V; Ramakrishnan. T; Sunil. S; Emmadi. Pamela. (2008) Soft TissuePreservation And Crestal Bone Loss Around Single-Tooth Implants. MD Journalof Oral Implantology .Vol. XXXIV. No. Four. Pages 223-229.

4. Kumar. A; Surendra. S. (2013) A new classification system for gingival andpalatal recession. J Indian Soc Periodontol. Vol. 17. Pages 175-181.

5. Tarnow DP, Magner AW, Fletcher P. (1992) The effect of the distance fromthe contact point to the crest of the bone on the presence or absence of theinterproximal dental papilla. J Periodontol. Vol. 63. Pages 995–996.

6. Salama H, Salama MA, Garber D, Adar P. (1998) The interproximal height ofbone—a guide post to predictable esthetic strategies and soft tissue contoursin anterior tooth replacement. Pract Periodont Aesthet Dent. Vol. 10. Pages1131–1141.

7. Langer B, Langer L. (1990) The overlapped flap: a surgical modification for implant fixture installation. Int J Periodontics Restorative Dent. Vol.10. Pages:209–215.

8. Miselli A. (2015). The “Umbrella Concept”. Unpublished article.

9. Miller PD Jr. (1987). Root Coverage with free gingival graft. Factors associatedwith incomplete Coverage. J.Periodontol. Pages 674-681.

10. Raetzke PB.(1985) Covering localized areas of root exposure employing the“Envelope” Technique. J. Periodontol. Pages 39 – 402.

Bernotti et al

Mahesh et al

Presence of adequate width of attached gingiva for longevity of implants has long been debated upon. The implant-mucosa

interface differs from the interface between the mucosa and natural teeth, and these differ-ences are important to the understanding of the susceptibility of implants to infection. Few stud-ies have examined the relationship between the width of keratinized mucosa and the health of peri-implant tissues. The results of these stud-ies are contradictory. Further studies are there-

fore required to clarify the role of the width of the keratinized mucosa around dental implants and their overall soft and hard tissue health. Most reli-able method for increasing WKG is autogenous free gingival graft. However the stability of FGG on the recipient site is of paramount importance for the uptake of graft. Traditional methods have described the use of sutures for achieving sta-bility of graft. Through this case report a suture-less technique is described where we achieve stability of FGG with help of soft tissue screws.

Soft Tissue Augmentation to Increase Width of Keratinized Tissue Around Dental Implants

Using Tissue Fixation Screws: A Novel Technique for Graft Tissue Stabilization

Dr. Lank Mahesh1 • Dr. Nitika Poonia1 • Dr. Vishal Gupta1

1. Dental Practice, India

Abstract

KEY WORDS: Mucogingival grafting, free gingival graft, width of keratinized gingiva, soft tissue screws

28 • Vol. 10, No. 3 • April 2018

Mahesh et al

INTRODUCTIONAlthough Lang and Löe1 concluded that 2 mm of keratinized tissue were necessary to main-tain periodontal health, this reported figure was refuted by Kennedy et al.2 The impor-tance of the amount of keratinized tissue around dental implants is still controversial. Experienced clinicians taking long term fol-low ups of their cases have never undermined the importance and role of attached gingiva in maintaining longevity of results in implan-tology. A study on monkeys and humans demonstrated dental implants without kera-

Figure 1: Pre-surgical photo demonstrating inadequate keratinized gingival tissue at recipient site.

Figure 2: Tacking kit.

tinized mucosa demonstrated significantly more recession and slightly more attachment loss than the other implants.3 The results sug-gested that the absence of keratinized mucosa around dental endosseous implants might increase the susceptibility of the peri-implant region to plaque-induced tissue destruction.

Various modalities exist to increase the width of keratinized gingiva around implants and to improve quality of soft tissue. Some of these techniques are apically positioned flap, v estibuloplasty, a llogeneic s oft t issue graft and autogenous soft tissue grafting.4 The soft tissue dimensions surrounding den-tal implants can further be improved by using mini-flaps, u sing s pecific in cision te chniques at the time of abutment connection (ie. U shaped incision, T shaped incision, modified Palacci technique and split finger t echnique). No soft tissue is removed in these modalities instead soft tissue is pulled in required direc-

tions which is usually buccal or interdental.


Mahesh et al

30 • Vol. 10, No. 3 • April 2018

Based on past scientific evidences, autog-enous FGG were proven to be effective and predictable in both animal models and humans in increasing the width of attached gingiva with high success rate. Traditionally FGG is har-vested from palatal site of the patient. Ideally anterior and premolar sites are chosen keep-ing incision 2mm away from free gingival mar-gin. Adipose and gland tissue on the graft are removed using scraping motion. After the donor tissue is shaped suiting the recipient site, tissue is fixed with periosteal sutures and sling sutures.5 In the view of the authors, one of the most diffi-cult aspects of a FGG and reason for its failure comes from inadequate fixation of tissue to the underlying bed. To overcome this authors have used soft tissue screws which resulted in immedi-ate stabilization of soft tissue graft to underlying connective tissue and resulted in faster healing.

CASE REPORTA 54 year female patient reported to the den-tal office for replacement of her posterior miss-ing teeth desiring dental implants, the patient had no relevant medical history. On examina-tion she had teeth 45,46, 47 (FDI tooth num-bering system) missing with adequate ridge width and height (Fig 1) as was observed on the panoramic radiograph. The mesiodis-tal width of the edentulous span was approxi-mately 20 mm. Therefore, it was decided to place three implant fixtures to support a por-celain fused to meatal bridge. The implants (Bioner, Barcelona) placed were 4 x 11.5mm in regions on 45 and 46 and an implant of 5 x 11.5mm at site 47. The implants were placed in a two staged (submerged proto-col) following manufacturer’s instructions.

Following an uneventful healing period the

Figure 3: Partial thickness preparation of recipient site and fixation of mucogingival tissue with screw.

Figure 4: Additional fixation of mucogingival tissues with screws.

Mahesh et al


Figure 5: Harvesting of free gingival graft.

Figure 6: Screw being used to fixate the free gingival graft to the recipient site.

Figure 7: Additional screws being used to fixate the free gingival graft to the recipient site.

Mahesh et al

32 • Vol. 10, No. 3 • April 2018

Figure 8: Well healed free gingival graft at recipient site creates a wider zone of keratinized gingival tissue around the dental implants.

Figure 9: Stable graft tissue seen at 12 months healing.

patient was recalled and on examination the tissue thickness around the implant area was observed as deficient. A soft tissue augmen-tation procedure with a free gingival graft har-vested from the palate fixed with soft tissue screws (Fig 2) was planned along with heal-ing collar placement on the implants. On the day of surgery an incision was placed at the mucogingival junction adjacent to the implants and a partial thickness flap was elevated and fixed with the soft tissue anchor screws

(Figs 3, 4). A free gingival graft (FGG) was harvested from palate (Fig 5) and fixated with the screws at the recipient site (Figs 6, 7). No sutures were used to secure the FGG. After healing (Fig 8), open tray impressions were recorded. A screw retained prosthesis was later delivered. Twelve month recall demon-strated stable peri- implant tissues (Fig 9).

DISCUSSIONThe role of stable peri-implant tissue for predict-able long term functional and esthetic outcomes of dental implants is an evidence based reality. This case report supports the view that narrow zones of keratinized gingiva are less resistant to insult along the implant-mucosa interface. When inflammation is present, its apical pro-liferation may occur more rapidly compared to those sites with wider zones of keratinized gin-

Mahesh et al


giva that have an epithelial seal. Wider zones of keratinized gingiva may offer more resistance to the forces of mastication and frictional con-tact that occur during oral hygiene procedures.6 Thus, a lack of keratinized gingiva may create an environment that is less amenable to oral cleansing and more susceptible to irritation and discomfort during such routine procedures.7 Sites with less keratinized tissue exhibit higher amount of peri implant recession.8 Different remodeling processes in keratinized and non-keratinized tissues or in the underlying bone over time, but especially during the initial heal-ing phase and the first 12 months after pros-thesis delivery, could explain these findings.9

CONCLUSIONIn this Case Report, a free gingival graft was used for augmentation. One disadvantages of using FGG is difficulty of fixation to underly-ing tissues. Hence, in this Case Report, fixa-tion screws were used to secure the graft in lieu of sutures. Using this technique, the FGG healed uneventfully and remained sta-ble after 12 months of follow up. The tech-nique of soft tissue graft fixation with screws offers an alternate to graft fixation with sutures, however more randomized clinical tri-als are needed to confirm this technique. l

Correspondence:Dr. Lanka [email protected]

DisclosureThe authors report no conflicts of interest with anything in this article.

References1. Lang NP, Löe H. The relationship between the width of keratinized gingiva

And gingival Health. J Periodontol 1972; 43: 623–627.

2. Kennedy JE, Bird WC, Palcanis KG, Dorfman HS. A longitudinal evaluation of Varying widths of attached gingiva. J Clin Periodontol 1985; 12:667–675.

3. Warrer K, Buser D, Lang NP, Karring T. Plaque-induced peri-implantitis in the Presence or absence of keratinized mucosa. An experimental study in monkeys. Clin Oral Implants Res 1995; 6:131–138.

4. Yan JJ,Alex Yi-min.Comparison of acellular dermal graft and palatal autograft in the reconstruction of keratinized gingiva around dental implants: A case report. Int J Periodontics Restorative Dent 2006;26:287-292

5. Hall WB, Lundergan WP. Free gingival grafts. Current indications and techniques.Dent Clin North Am 1993; 37:227–242.

6. Alpert, A. (1994). A rationale for attached gingiva at the soft-tissue/implant interface: esthetic and Functional dictates. Compendium of Continuing Education in Dentistry 15:356, 358, 360-2 passim; Quiz 368.

7. |Horning GM, Mullen MP. Peri-implant free gingival grafts: Rationale and technique. Compend Contin Educ Dent 1990; 11: 604–610.

8. Quarrymen, M., De Soete, M. & van Steenberghe, D. (2002) Infectious risks for oral implants: a review Of the literature. Clinical Oral Implants Research 13: 1–19.

9. Bengazi, F., Wennstrom, J.L, & Lekholm, U. (1996) Recession of the soft tissue margin at oral implants. A 2-year longitudinal prospective study. Clin Oral

Mahesh et al

Falcón-Guerrero

The success of the processes of horizon-tal bone augmentation requires that the procedure has a tension-free closure.

The greatest challenge in these regenerative techniques is to establish a flap design that covers an increased dimension after the bone graft had been applied to the defect; for this objective there are frequently using alterna-tives, but they cause loss of vestibular depth

and keratinized mucosa, that cause functional and aesthetic discomfort. This preliminary report describes a new surgical technique that uses a palatal flap of apical reposition (Waya Tech-nique) for primary tension-free closure in max-illae bone augmentation that eliminates the secondary effects of traditional techniques, being a new alternative to take into account in the procedures regenerative of the maxilla.

The Waya Technique: A Novel Approach Using a Palatal Flap of Apical Repositioning for Primary

Tension-Free Closure in Maxillary Bone Augmentation

Britto Falcón-Guerrero, DDS, MDS, PhD1

1. Private Practice. Tacna, Perú

Abstract

KEY WORDS: Mucogingival graft, maxilla, bone graft, dental implants

34 • Vol. 10, No. 3 • April 2018

Falcón-Guerrero


INTRODUCTIONDefects of the alveolar ridge represent seri-ous problems when planning implants, fixed or removable prostheses.1 The presence of alveo-lar ridge defects due to bone resorption has led to the development of many bone augmenta-tion procedures with the intention of improving the quantity and quality of the bone to achieve a predictable dental implant treatment.2 There are several surgical techniques to increase alveo-lar crests with reduced thickness that can be classified as: 1) guided bone regeneration; 2) bone block grafts; 3) ridge split and; 4) distrac-tion osteogenesis. Each of these techniques should always be accompanied by vascularized flaps.3 These reconstructive efforts are limited in the efficacy due to inadequate flap coverage and vascular perfusion. Procedures to prevent the collapse of the alveolar ridge are highly tech-nique sensitive and require different surgical designs depending upon the size of the defect.4

Primary closure results in decreased discom-fort and faster healing, Failure to attain tension-less closure may result in a soft tissue dehiscence along the incision line that can cause a poor outcome and/or postoperative complications.5

Figure 1a: Preoperative panoramic radiograph and cone beam computed tomography scan showing inadequate alveolar ridge width for implant placement.

Figure 1b: Preoperative panoramic radiograph and cone beam computed tomography scan showing inadequate alveolar ridge width for implant placement.

Figure 1c: Preoperative panoramic radiograph and cone beam computed tomography scan showing inadequate alveolar ridge width for implant placement.

Falcón-Guerrero

36 • Vol. 10, No. 3 • April 2018

The flap design must serve primary tension-free closure would need to be achieved over an increased dimension after the bone graft had been applied to the defect. The key to achieving wound closure is not only the clinician’s ability to obtain tension-free release flap but also good soft tissue quality and quantity. In an attempt to achieve wound closure and hence graft stabil-ity, the buccal mucosa is often broadly released, and this often results in a severe apical translo-cation of the mucogingival line, loss of vestibule,

Figure 2: Preoperative situation with a low insertion of the lateral frenum.

Figure 3: Incisions in the palate, covering 6 mm of this area.

Figure 4: Partial-thickness flap from the palatal area to the alveolar crest.

Falcón-Guerrero


and keratinized mucosa, even limiting the mobil-ity of the lip. When the vestibule becomes shal-low, it often leads to an esthetic challenge as well as a phonetics problem. Moreover, research has shown that areas with minimal keratinized mucosa often have a higher peri-implant plaque accumu-lation, inflammation, and attachment loss.6,7,8,9,10

One of the basic principles of surgery is flap design and simplicity should be a key goal with unnecessary complexity avoided.5,11

Taking into account these antecedents where some unwanted effects of the coronally advanced flap are seen, the aim is to present a preliminary report of a new approach with a palatal flap of apical reposition (Waya Technique), to attain pas-sive coverage of the wound and maintain a pre-dictable flap closure during the entire healing period, seeking to demonstrate the simplicity, predictability and simplicity of this new proposal.

CASE PRESENTATIONA 61-year-old woman with a history of con-trolled diabetes mellitus presented to the office to rehabilitate the maxilla with an overdenture on implants. At the initial visit, the patient underwent clinical examination with periapical and panoramic

radiographs and study models. Then a computed tomographic scan evaluation was accomplished to plan implant surgery. After the radiographic study it was determined to install two implants in the canine and an upper premolar area and the tomographic study a substantial horizontal bone defect was apparent (figs 1a,1b and 1c). Clini-cally, this area presented a low insertion of the lateral frenum, which suggested a plan of coro-nal repositioning flap to avoid a tear of the suture (fig 2). Anatomic issues in this area also included

Figure 5a: Passive elevation of full-thickness flap to expose the atrophic alveolar ridge.

Figure 5b: Passive elevation of full-thickness flap to expose the atrophic alveolar ridge.

Falcón-Guerrero

38 • Vol. 10, No. 3 • April 2018

a shallow vestibule, so it was proposed to use a new technique with a palatal flap of apical reposi-tioning to avoid problems and achieve a suture by tension-free primary closure. The treatment plan consisted of two immediate implant placements in conjunction with ridge split and guide bone regeneration. The patient did not accept any treatment with bone grafts, nor maxillary sinus lift. The patient received through explanations of the process and signed a written informed consent form prior to being start the surgery. The patient received antibiotic prophylaxis beginning prior to

surgery (2 g amoxicillin 1 hour prior to surgery). After rinsing with a 0.12% chlorhexidine-digluco-nate solution and application of local anesthesia in the zone of surgery, a vertical incision mesial and distal on the buccal zone was performed with a surgery blade 15-C. These incisions were pro-jected to the palatal area, covering 6 millimeters of this area (this will compensate the projection of the flap to cover the regenerated area) and achieve tension free suture (fig 3). First, we raised a partial-thickness flap from the palatal area to the alveolar crest (leaving only connective tissue on

Figure 6a: Ridge split procedure. Figure 6b: Ridge split procedure.

Falcón-Guerrero


Figure 7: Passive suture of flap without modifying the muco-gingival junction.

the palatal side), being careful prevent flap perfo-ration (fig 4). Secondly, from the crest to the buc-cal side, a full-thickness mucoperiosteal flap was elevated to expose the entire all the bone surfaces to make the ridge split and, make the regenera-tion (figs 5a and 5b). The osteotomies were per-formed directly on the bone to divide the crest, the division is made with chisels and two implants are installed to replace the canine and the sec-ond right upper premolar, the bone regeneration is made with particulate bone and barrier membrane,

and then replenish the flap (figs 6a and 6b). The mattress and interrupted suture are made with 4-0 chromic catgut and acid polyglycolic 5-0, achiev-ing a totally passive and tension-free suture of the entire operated area. Without presenting any change or alteration of the vestibule or the muco-gingival junction, there is freedom of mobility of the lip and an anti-aesthetic situation not seen, achiev-ing the comfort of the patient from the immediate postoperative period. On the palatal side there is a zone of exposed connective tissue that regen-erates by second intention (fig 7). Following sur-gery, patient was instructed to rinse with 0.12% chlorhexidine-digluconate two times daily for at least 3 weeks. To reduce swelling, naproxen sodic 550 mg was prescribed. A follow-up exam per-formed at 5 months, observing good stability and healing of all the flaps (figs 8a and fig 8b).

DISCUSSIONManagement of horizontal alveolar ridge defects has greatly evolved over the last few years, allow-ing for implant placement under predictable condi-tions.1 One of the key factors in the final outcome is the maintenance of primary closure of the flaps with tension-free for the entire healing period. Greenstein et al. concluded that the tension-free primary closure is attainable so long as the flap is advanced.5 Therefore, the flap design will be directed at the primary tension-free closure after the bone grafting procedure despite the increased size of the ridge.12 Flap advancement in the pos-terior maxilla is a relatively safe procedure that can be accomplished with minimal complications, but in large displacements you must have exten-sive knowledge of the anatomy to avoid damag-ing vessels and nerves that run through this area.5

Various conventional technical approaches

Falcón-Guerrero

40 • Vol. 10, No. 3 • April 2018

Figure 8a: Healing at 12 days. Figure 8b: Healing at 5 months.

are available to provide coverage of regenera-tion procedures. When there is insufficient tis-sue to cover the surgical area, studies suggest cutting deeply in the muscle layer, entering again in the first incision, or performing a new perios-teal release parallel to the first and with the same modalities to achieve elasticity of the flap.13 In extreme cases, the internal preparation of the flap under the periosteum can be carried out anteri-orly close to the lip below the orbicularis muscle without damaging its fibers. With this flap, coro-nal manipulation is called the “suborbicularis preparation”14 and requires suturing the flap in two layers to avoid tearing by the tension.12 A flap that is too small is difficult to manage and is often responsible for early membrane or graft exposure that leads to poor clinical outcomes.14

These approaches are effective but have some limitations: deep linear cuts in the muscle layers are performed without a direct visual con-trol and can interrupt blood vessels and nerve fibers of variable importance, increasing the incidence of intraoperative and postoperative complications (eg, immediate or delayed bleed-ing, hematoma, edema, neurological injuries).15

Urban et al. proposed four clinical condi-tions when considering tension-free primary

closure: 1) shallow vestibule with healthy perios-teum; 2) deep vestibule with healthy periosteum; 3) shallow vestibule with scarred periosteum,and; 4) deep vestibule with scarred periosteum.Tension-free closure allows clinicians to achievemore predictable vertical bone gain. But there isalways a change of soft tissue shift after closure,often resulting in a severe apical translocation ofthe muco-gingival junction and loss of the ves-tibule and keratinized mucosa. This may lead toesthetic and phonetic problems as well as higherperi-implant plaque accumulation, inflammation,and attachment loss.14 Considering the thick-ness of the gingival and palatal epithelium that is0.3 mm - 0.8 mm and sub-epithelial tissue widththat varies from 1.25 mm to 3 mm (together,having a thickness ranging from 2.5 mm to 3.7mm, with a mean of 2.8 mm),16,17 that providesa good amount of tissue that is used to achievethe extension of a palatal flap with apical repo-sitioning to help cover the regeneration zone,without any tension when repositioning the flap.

The case report in this article demonstrates a simple approach (Waya technique) that allowed for improved guidance to achieve a flap that allows covering in a more predictable way to the operated area, achieving a total tension-

Falcón-Guerrero


free closure that remains stable throughout the regeneration time and avoiding the undesired results of traditional techniques. Advantages of the Waya technique include the follow-ing: 1) there is no risk of producing neural or blood vessel damage because it is not neces-sary to go deep into the vestibule, reducing the possibility of hematoma, edema and inflamma-tion; 2) the muco-gingival junction and the bot-tom of the vestibule are conserved, avoiding the limitation of lip movement, phonetic problems and the patient’s anti-aesthetic appearance; 3) the keratinized gingiva is preserved, whichavoids plaque retention problems, attachmentloss, peri-implant plaque accumulation and; 4)allows greater patient comfort from the immedi-ate postoperative period. It can become a viablealternative that can be well accepted within the pro-tocols of regenerative treatments in Implantology.

CONCLUSIONThis preliminary report describes a new surgical technique that uses a palatal flap of apical repo-sitioning (Waya technique) for primary tension-free closure in maxillary bone augmentation that eliminates the secondary effects of traditional techniques. This technique shows satisfactory clinical results, both for the surgical procedure and for the patient, being a new alternative to take into account in the regenerative procedures of the maxilla. In contrast, it is a delicate procedure and if do not have much practice you can lacer-ate the flap, so it demands more execution time. l

Correspondence:Dr. Britto Falcó[email protected]

DisclosureThe authors report no conflicts of interest with anything in this article.

References 1. Falcón Guerrero BE. Manejo de los defectos horizontales del reborde alveolar.

JPAPO 2017; 2(1):30-39.

2. Falcón B. Multidisciplinary approach for treatment of severely resorbed maxillary anterior ridge complicated by cysts in a single surgical session. J Implant AdvClin Dent 2015; 7(9):23-29.

3. Fu JH, Wang HL, Horizontal bone augmentation: the decision tree. Int JPeriodontics Restorative Dent. 2011 Jul-Aug;31(4):429-36.’

4. Langer B, Calagna LJ. The subepithelial connective tissue graft: A new approach to the enhancement of anterior cosmetics. Int J Periodontics RestorativeDent. 1982;2:22–33.

5. Greenstein G, Greenstein B, Cavallaro J, Elian N, Tarnow D. Flap Advancement: Practical Techniques to Attain Tension-Free Primary Closure. J Periodontol2009; 80:4-15.

6. Gobbato L, Avila-Ortiz G, Sohrabi K, Wang CW, Karimbux N. The effect ofkeratinized mucosa width on peri-implant health: A systematic review. Int J OralMaxillofac Implants 2013;28:1536–1545.

7. Urban IA, Nagursky H, Lozada JL, Nagy K. Horizontal ridge augmentation witha collagen membrane and a combination of particulated autogenous bone andanorganic bovine bone-derived mineral: A prospective case series in 25 patients. Int J Periodontics Restorative Dent 2013;33:421–425.

8. Urban IA, Lozada JL, Jovanovic SA, Nagursky H, Nagy K. Vertical ridgeaugmentation with titanium-reinforced, dense-PTFE membranes and acombination of particulated autogenous bone and anorganic bovine bone-derived mineral: A prospective case series in 19 patients. Int J Oral MaxillofacImplants 2014;29:185–193.

9. Urban IA, Monje A, Lozada J, Wang HL. Vertical Ridge Augmentation and SoftTissue Reconstruction of the Anterior Atrophic Maxillae: A Case Series. Int JPeriodontics Restorative Dent 2015;35:613–623.

10. Urban IA, Lozada JL, Nagy K, Sanz M. Treatment of Severe MucogingivalDefects with a Combination of Strip Gingival Grafts and a Xenogeneic Collagen Matrix: A Prospective Case Series Study. Int J Periodontics Restorative Dent2015; 35:345-353.

11. Falcón Guerrero BE. Efectividad de un injerto pediculado de tejido conectivopara lograr el cierre por primera intención en implantes post extracción. Vis.dent. 2014; 17(1): 176-181.

12. Urban IA, Monje A, Lozada JL, Wang HL. Long-term Evaluation of Peri-implantBone Level after Reconstruction of severely Atrophic Edentulous Maxilla viaVertical and Horizontal Guided Bone Regeneration in Combination with SinusAugmentation: A Case Series with 1 to 15 Years of Loading. Clin Implant Dent Relat Res. 2017 Feb; 19 (1): 46-55.

13. Romanos GE. Periosteal releasing incision for successful coverage ofaugmented sites. A technical note. J Oral Implantol 2010;36:25–30.

14. Urban IA, Monje A, Nevins M, Nevins ML, Lozada JL, Wang HL. SurgicalManagement of Significant Maxillary Anterior Vertical Ridge Defects. Int JPeriodontics Restorative Dent 2016;36:329–337

15. Ronda M, Stacchi C. A Novel Approach for the Coronal Advancement of theBuccal Flap. Int J Periodontics Restorative Dent 2015;35:795–801.

16. Greenstein G, Cavallaro J, Tarnow D. Application of Anatomy for the DentalImplant Surgeon. J Periodontol 2008;79: 1833-1846.

17. Kolliyavar B, Setty S, Thakur SL. Determination of thickness of palatal mucosa.J Indian Soc Periodontol 2012;16: 80-3.

Falcón-Guerrero

rebuilding buccal plate deficiency during immediate ... · allow an immediate implant placement...

Documents