Soft Tissue Management
In Implant Dentistry
Soft Tissue Management in Implant Dentistry
A) Incision Design
B) Flap Reflection
C) Release and Closure
D) Soft Tissue Enhancement around Implants
“Expose as much as needed”
"PASS" Principles for Predictable Bone Regeneration
Primary wound closure
to ensure undisturbed and uninterrupted wound healing
Angiogenesis
to provide necessary blood supply and undifferentiated mesenchymal cells
Space maintenance/creation
to facilitate adequate space for bone ingrowth
Stability
of wound and implant to induce blood clot formation and uneventful healing
A) Incision design
1. Incisions made along the edentulous area (crestal, para-crestal)
2. Incisions made along the gingival margin (horizontal incisions)
3. Papilla management
4. Releasing incisions
1) Incisions made along the Edentulous Area
Crestal incision
Para-crestal incision
Buccal
• These vessels run parallel to the alveolar ridge in the vestibulum most of the
time, only gingival branches stretch to the alveolar ridge.
• The crestal area of the edentulous alveolar ridge is covered by a 1–2mm wide
avascular zone with no anastomoses crossing the alveolar ridge.
Kleinheinz et al. 2005
• The mid-crestal incision seems to be the ideal choice for the edentulous area of
the planned implantation. Making the cut in the area of the avascular zone
prevents the risk of cutting through anastomoses or cutting out avascular areas of
the mucosa.
• For esthetic reasons, only marginal incisions should be used in the frontal
region.
• Lower arch:
We rarely go for Para-Crestal Incisions
• Upper arch:
1) Buccal Para-Crestal
• Upper arch:
2) Palatal para-crestal
2. Incisions made along the Gingival Margin (horizontal incisions)
Marginal Incision
Para-Marginal Incision
3. Papilla Management
4. Releasing Incisions
Horizontal releasing incision
Whenever possible, for esthetic reasons only marginal incisions should be used in the frontal region.
Releasing incisions in the vestibulum should be avoided because they will cut obliquely through defined
esthetic zones and not at their borders.
Kleinheinz et al. 2005
Vertical releasing incision
Releasing incisions should be carried out, if at all, only at the
anterior border of the incision line to avoid cutting through the
vessels coming from posterior to anterior.
Kleinheinz et al. 2005
B) Flap reflection
Partial Thickness Flap
Full Thickness Flap
C) Release and closure
Histology of Incised Tissues
Histology of Incised Tissues
Submucosa, consists of strands of densely grouped collagenous fibers and
loose connective tissue containing adipose, small mixed glands, blood vessels,
and nerves. In general, the submucosa is loosely textured and contains
numerous elastic fibers.
Firmly attached to the buccinator muscle in the cheek area and the orbicularis
oris adjacent to the lips
Periosteum, a thin wrap of dense connective tissue, up to 0.375 mm; it is
bound down and is not very flexible because of the lack of elastic fibers.
Regional Anatomic Considerations
Posterior Maxilla
Buccal Aspect
Relatively safe
Vital structures like vessels, nerves and Stenson’s duct are located
deep to the area of release.
Palpate the infraorbital notch. it is advisable not to incise too
deeply into the tissues, because it is unknown precisely where
branches of the blood vessels and nerves reside.
Palatal Aspect
Anterior Maxilla
Posterior Mandible
Anterior Mandible
Submental and Sublingual Arteries
Buccal Flap Advancement
1) Minor Flap Advancement (several millimeters)
1) Elevate a full-thickness flap (periosteum included) apically to the buccal
vestibule.
2) Extend the release mesially and distally under the periosteum.
2) Moderate Flap Advancement (3 to 6 mm)
1) Horizontal incision across the edentulous area.
2) Vertical releasing incisions on the buccal aspect.
3) Elevate a full-thickness flap and extend it apically to the
vestibule.
4) Scoring
5) Blunt dissection
6) Scoring the periosteum can be repeated3 to 5mm away from the
initial periosteal fenestration.
2 3
3) Major Flap Advancement (≥7 mm)
Cut deeper into the submucosa to separate the muscle attachment
A dome-shaped incision is made around the foramen. If the
distance from the base of the flap to within 3 mm of the coronal
margin is 6 mm (A), then the dome-like incisions made on each
side of the foramen is 1/2 A.
Tarnow et al. 2009
Lingual Flap Advancement
• Suturing (in Implantology and Periodontology)
Wound closure sutures • Interrupted sutures
• Vertical mattress
sutures
• Continuous sutures
Tension relieving sutures • Horizontal internal
mattress sutures
• Internal sutures
Combination sutures • Double sling sutures
(closure + tension relieving)
Suspension sutures • Sling sutures • Vertical sling sutures
• Periosteal sutures • Horizontal sling sutures
Fixation sutures
(immobilize the flap)
Positioning sutures
(in tunneling technique)
Thank You
