Current Concepts in Craniofacial Surgery

Abstract

Modern periodontal plastic surgery evolved from traditional resective periodontal surgery as a result of the development of various reconstructive and regenerative surgical techniques. The impetus for these surgical and biotechnological developments was an increased public awareness and demand for esthetic dental services. Today periodontal plastic surgery techniques fall under the realm of “cosmetic periodontal surgery” and “esthetic implant site development” having applications in cosmetic dentistry as well as implant therapy. These procedures are “Plastic” in nature and are utilized to manage vestibular insufficiency, aberrant frenum, marginal tissue recession, excessive gingival display, lost interdental papillae, deficient alveolar ridges, as well as in the preservation of alveolar hard and soft tissues following tooth removal in preparation for implant therapy or conventional prosthetic restorations. An anatomic basis exists for the successful application of these techniques to both periodontal and peri-implant hard and soft tissues. Most importantly, the clinician must understand that the peri-implant soft tissues lack a connective tissue attachment to the permucosal implant structures, and do not enjoy the blood supply normally derived from the periodontal ligament around natural teeth. In addition, the peri-implant soft tissues do not enjoy the potential vascular anastomotic connections present in the periodontal soft tissues. These important anatomic differences render the peri-implant soft tissues more vulnerable than periodontal tissues to mechanical and bacterial challenges and can limit the soft tissue volume yielded from the various soft tissue reconstructive procedures performed at implant sites. Nevertheless, soft tissue preservation and reconstructive techniques can be utilized not only enhance the esthetic results obtained in the partially edentulous implant patient but also to improve the functional results obtained when implant therapy is utilized to treat the edentulous patient suffering from alveolar atrophy. Application of these techniques in implant therapy requires a meticulous surgical technique and strict adherence to the basic principles governing oral soft tissue grafting procedures. With an understanding of periodontal and peri-implant soft tissue anatomy, and the principles of oral soft tissue grafting, the clinician can select, sequence and successfully apply soft tissue grafting techniques to enhance functional and esthetic results in implant therapy. In esthetic implant therapy; preservation or recreation of natural alveolar ridge anatomy is a prerequisite for success. When present at the implant site, natural hard and soft tissue alveolar ridge contours allow both ideal implant placement and the emergence of a restoration that is harmonious with the adjacent dentition and free from prosthetic compensations. Again the successful application of surgical techniques designed either to preserve existing alveolar ridge contours or to reconstruct missing hard and soft tissue volume at an implant site is based upon a clear understanding of both periodontal and peri-implant anatomy and their individual responses to the multitude of surgical and prosthetic interventions often required in esthetic implant therapy. Armed with an understanding of local anatomy, concepts of plastic and reconstructive surgery can be successfully applied in implant therapy to preserve or reconstruct natural hard and soft tissue contours in an inconspicuous fashion providing the restorative dentist with the necessary foundation for the creation of a beautiful restoration. When utilized during hard or soft tissue alveolar ridge reconstruction, cosmetic incisions and optimal flap designs that preserve the circulation to the area not only maximize the volume of tissue obtained from each reconstructive procedure but also ensure an inconspicuous appearance. Similarly, these surgical approaches can be utilized during implant placement or exposure to maximize esthetics and preserve soft tissue volume in the areas critical for prosthetic emergence. When hard tissue reconstruction is performed, a synergistic effect is obtained by combining plastic and reconstructive surgery techniques with the currently available bone grafting biotechnology. In addition, customized “tooth form” healing abutments and implant provisional restorations fabricated from a surgical indexing at the time of fixture placement can be utilized in synergy with soft tissue reconstructive procedures to guide the preserved or reconstructed peri-implant soft tissues to a natural appearance. Ultimately, the contours incorporated in the healing abutments and provisional restorations have tremendous influence on the final soft tissue architecture and esthetics of the restoration. Once the natural alveolar ridge anatomy has been successfully reconstructed, cosmetic laser soft tissue resurfacing is performed to ensure that reconstructed peri-implant soft tissues are free from surface irregularities and blend naturally with adjacent periodontal tissues. Laser sculpting procedures Surgical Mini-Lectures