Page 11 - GP Spring 2022

regarding space maintenance, resorbable (Platelet-Derived Growth Factor), TGF- the anatomical considerations for success-
membranes are not as successful as the (Transforming Growth Factor-beta), VEGF ful implant placement require at least 1 mm
non-resorbable membranes. (Vascular Endothelial Growth Factor), of bone all around the dental implant in the
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EGF (Epidermal Growth Factor), FGF (Fi- posterior region and, for best aesthetic re-
Non-resorbable membranes are well docu- broblast Growth Factor), and IGF (Insulin sults, 2 mm on the buccal surface of anteri-
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mented in the literature and research has Growth Factor). PRF membrane has bet- or implants. 32,33
shown a long-term success of 93% in over ter results than platelet-rich plasma (PRP)
12.5 years. However, one of the e-PTFE since the fibrin material releases growth Clinical Presentation
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drawbacks is that the membrane must be factors and cytokines during the healing A forty-two-year-old male presented to our
removed prematurely if it is exposed prior phase. 28,29 office with a chief complaint of, “My tooth
to complete healing because early exposure fell out.” (Figure 3).
can result in bone contamination and soft PRF also has shown much better results in
tissue inflammation. root coverage of natural teeth with gingival
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recession than an acellular dermal matrix.
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Studies have shown that implant placement
in conjunction with the GBR has a surviv- Implant Position Considerations
al rate of 91.9% to 92.6% compared to a The implant place-
94.6% survival rate with the implants in the ment needs to follow
native bone without the GBR. the three-dimensional
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approach: buccal-lin-
Soft Tissue Considerations gual, mesio-distal, Figure 3. Patient missing tooth #8.
Figure 3. Patient missing tooth #8.
Soft tissue considerations are important for and apical-coronal. 31
achieving an optimal result in the aesthetic (Figure 1) The patient reported that his tooth started
zone. Creating a functional result without getting loose on its own two months ago.
good aesthetics is unacceptable to the pro- Figure 1. Incorrect With thin biotypes He also reported no significant medical his-
Figure 2. Titanium showing through the soft
vider as well as the patient. Several tech- implant placement. and highly scalloped tory, medications, or allergies, and denied
Figure 1. Incorrect Implant placement.
niques for soft tissue grafting have been tissue, the implant a smoking history. After a complete oral
tissue.
introduced in the literature, including au- needs to be placed more palatally and examination, a lack of proper home care
togenous tissue graft, collagen matrix, and slightly deeper to hide the titanium from was noted. The adjacent teeth had probing
dermal matrix. The gold standard is still showing through the soft tissue (Figure 2). depth between 2-3 mm, and mobility was
the autogenous tissue graft to optimize the within normal limits. The patient also pre-
keratinized mucosa (KM). Studies have sented with a thick band of KM and favor-
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shown that KM thickness helps with the able bio-type with adequate papilla to the
aesthetic outcome and creates a healthier mesial and distal of the missing tooth.
environment for the long-term success of
the dental implant. 19,20 Healthy KM around This patient’s expectation was to correct
the cervical aspect of the implant will cre- the defect and to replace his tooth with a
ate a biological seal that prevents bacterial dental implant to attain the best possible
invasion and provides better hygiene and aesthetic outcome.
comfort. 21-23 The success of KM surgery Figure 2. Titanium showing through the soft
is unrelated to the stage in which it is per- tissue. Case Management
formed, whether during the implant place- Phase I included full mouth hygiene and
ment or the GBR. In addition, the rule of six that was intro- home care instructions. 3D Cone Beam
duced by Cooper et al. can be used to place Computer Tomography (CBCT) was taken
In cases of trauma, the process of tissue the implant in the proper 3D location : before the surgery to assess the bone defi-
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healing is very unpredictable, and most ciency and create a proper treatment plan
patients require tissue augmentation in ad- 1. 6 mm buccal-lingual osseous dimen- for the case (Figure 4).
dition to the GBR. Besides the aesthetic sion
considerations, the thickness of KM can 2. 6 mm in length at minimum
improve peri-implant health and marginal
bone remodeling. 24,25 Amongst the autoge- 3. 6 mm of inter-radicular space
nous graft techniques, the Palatal Pedicle 4. 6 mm in length at minimum
Flap (PPF) can improve the result due to
preservation of the vascularity, which re- 5. 6 mm interocclusal space
sults in optimal coloration and less tissue 6. Less than 6 mm distance between
shrinkage. 26,27 the contact point and crestal bone;
and the implant needs to be placed Figure 4. 3D Cone Beam Computer Tomog-
Platelet-Rich Fibrin (PRF) 3 mm apical and 2 mm palatal to the raphy (CBCT) was taken before the surgery to
Figure 4.
PRF is a concentrate from a patient’s own gingiva. 3D Cone Beam Computer Tomography (CBCT) was taken before the
assess the bone deficiency and create a proper
surgery to assess the bone deficiency and create a proper treatment
blood which is drawn in the office on the plan for the case,
treatment plan for the case.
day of the surgery. This concentrate is The implant needs to be placed 1 mm
pressed, flattened out, used as a membrane below the cemento-enamel junction api- On the day of surgery, the procedure in-
and auto-scaffolded in the GBR around cal-coronally. The buccal-lingual position cluded GBR and GTR with healing time
the implant or natural dentition. After the should be 2 mm from the midfacial gingi- planned before implant placement. The
PRF membrane is placed into the area, it val margin and 1.5 mm mesio-distal posi- patient agreed to the staging and length of
releases growth factors including PDGF tion from the adjacent teeth. In summary,
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