A minimal invasive periodontal surgery around implant

Abstract

Background Various soft tissue manipulations during bone augmentation surgeries, in particular in order to obtain primary and watertight closure of the flaps, weaken the soft tissues. This modification is accompanied by a severe loss of keratinized tissue (KT) and vestibular depth and thereby with displacement of the mucogingival line. The aesthetic and biological integration of implant-prosthesis is directly related to the presence of favorable mucosal conditions. Aim/Hypothesis This case series study was performed to evaluate the quantity and quality of keratinized tissue in 13 sites following the combination of the strip gingival graft technique described by Urban with the use of a xenogeneic collagen matrix over a period of 36 months. Material and Methods 13 sites where selected on healthy and non-smoker 11 patients with a mean age of 59.13 years (range- 22 to 78.5 years, 1 male, 10 females). A combination technique using a free strip gingival graft sutured to the apical end of the recipient bed and a xenogeneic collagen matrix sutured on the coronal bed was done. The strip was harvested from the palate and had only 3 mm wide. The primary outcome measurement was the increase in the width of KT between baseline (T0 at 10 days after surgery) and 36 months post-surgery (T36). The augmented tissue was assessed with a calibrated periodontal probe from the apical extension of the strip graft to the established reference point at T0 and T36. The secondary outcome was the degree of graft shrinkage, expressed in percentage and calculated by measuring the graft contours with the probe in place at T0 and T36. The patient's pain was recorded through a visual analog scale. Postoperative complications, such as infection and bleeding was recorded. Results After 36 months, significant gain in KTW, with an average width at 36 months of 6.15 mm was observed (range between 4 and 9). The percentage of shrinkage was 48.70%. The regenerated soft tissue demonstrated a good healing and homogeneity with the neighboring tissues in 6 sites whereas in 7 sites there where a significant difference of color and texture. Coral pink color was the main color of the gum. Some pale pink white color was observed at the contour. Bridles were observed in 7 sites specially at the contour and the apical end of the strip graft. No postoperative complications, such as intense pain, infection, or bleeding where noticed. No patient complained of pain on the donor site which rapidly epithelialize. All patient required continuous pain medication during the first post-operative 3 days. The score from VAS varies from 1 to 7 (mean 2.61). Paracetamol codeine was the main prescribed molecule. Only one patient needed tramadol. No problem on chewing was noticed. Conclusion and Clinical Implications The strip gingival graft is minimal invasive and seems effective muco-gingival surgery to restore severe loss of keratinized tissue with a minimum of post-operative complications. This gingival graft technique is promising to better the comfort for the patient and reduce morbidity. However, due to unpredictable aesthetic result, it is better to limit this muco-gingival graft on posterior sites. Larger group of patients and long term assessment must be conducted in order to confirm these results.