Soft tissue management for large bone augmentation

soft tissueAlfonso Rao discusses the use of soft tissue grafting procedures ahead of dental implant treatment and the use of and benefits offered by soft tissue substitutes.

The stability of hard and soft tissues plays a pivotal role in oral rehabilitation success – both functionally and aesthetically. This makes the achievement of optimal results more challenging and leads to a greater consideration of all the contributing factors.

The collapse of the alveolar ridge in an edentulous area in patients who will undergo oral rehabilitation impedes the harmonic relationship between pontic and ridge. To correct this type of defect there are several surgical techniques that aim to achieve soft tissue augmentation. This allows for the conformation of an ideal profile with the use of a pontic.

The significance of soft tissue augmentation

Clinical evidence shows that soft tissue augmentations contribute to more than 40% of the final soft tissue volume at implant sites. It also results in superior aesthetics, higher papilla scores and less mucosal recession. In addition, initial gingival tissue thickness at the crest might be considered important for marginal bone stability around implants. 

Linkevicius and colleagues (2015) were indeed able to demonstrate that if tissue thickness is 2mm or less, crestal bone loss of up to 1.45mm may occur, despite a supracrestal position of the implant-abutment interface.

Soft tissue augmentation strategies

Periodontal or peri-implant plastic surgery procedures have been successfully performed to restore the shape and dimensions of soft and hard alveolar tissues before, during or after implant placement. 

These procedures include ridge augmentation with soft tissue, where autologous subepithelial connective tissue grafts are considered the gold standard.

Nevertheless, the use of autologous tissues is associated with disadvantages. Typically, the quantity and quality of tissue that can be harvested vary depending on the shape of the palatal vault. As well as the patient’s sex and age, along with anatomical factors, such as a thick alveolar process, exostosis, and the palatine nerves and blood vessels. 

In addition, because of the harvesting procedure, which leads to a prolonged healing time at the donor site, patients often complain about pain and numbness for several weeks after surgery.

Therefore, to reduce the morbidity and overcome the disadvantages of autologous grafts, soft tissue substitutes represent a great advantage, particularly because bigger areas can be treated in a single surgery.

Our alternative experience 

In recent clinical studies comparing a xenogeneic, volume-stable collagen matrix (Geistlich Fibro-Gide) to autologous connective tissue grafts at implant sites, at one-year follow-up, the matrix showed no significant differences in terms of quality and quantity of the stable, augmented soft tissue. 

In addition, there was no need for a second surgical site, and patients benefited from a lower pain perception. Similarly, in aesthetic sites, Chappuis and colleagues (2018) demonstrated that using the matrix for soft tissue augmentation simultaneously with guided bone regeneration and implant placement is safe and feasible.

We have been using Geistlich Fibro-Gide in our practice to treat mild or moderate ridge defects, for which soft tissue augmentation is generally enough to repair the deformity. 

Case study

The aim of the clinical case presented in this article was to increase the thickness of the soft tissue at the pontic site. 

Visibly, the matrix was secured in the desired area and helped to achieve a good outcome. 

Although long-term studies are still required, reduced morbidity, unlimited quantity and standardised quality make Geistlich Fibro-Gide a good option. It opens doors for patients who fear autologous graft harvesting procedures. Or simply do not have the quantity or quality necessary for graft harvest. 

Now there is an alternative to the connective tissue graft, making the surgeon’s life easier.

Treatment recommendations

Thickening of soft tissue is beneficial to improve the aesthetics of restorations but even more important for marginal bone stability implants.

Geistlich Fibro-Gide can be used at the time of implant placement, or alternatively it can be placed during implant uncovering. It can also be used for conventional prosthetic rehabilitation.

It is important to trim Geistlich Fibro-Gide to the desired size to fit into the defect. The device will transiently gain approximately 25% in volume upon wetting, so consider the swelling when determining the final dimensions. 

The mobilisation of a generous flap is key to managing particularly large defects. This also assures full coverage of the matrix.

To achieve predictable results, Geistlich Fibro-Gide should be submerged without exposure. Close to wound margins, reducing the thickness of the matrix by 2-3mm might be beneficial to avoid dehiscences during the healing phase.

A dehiscence and exposure of the matrix can happen. Nevertheless, in our experience no infections have been detected and no premature removals of the matrix have been necessary. 

Suturing the device to the underlying soft tissue is advisable to secure the matrix, reducing the risk of dislocation.    

 This article first appeared in Clinical Dentistry magazine. For more articles like this you can sign up to the magazine here.

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