Discussion
This technical report introduced a different approach for soft tissue
contouring for implants in the esthetic zone. Traditionally,
peri-implant tissue is contoured after the insertion of the implant
placement. However, soft-tissue contouring prior to implant placement
may provide a more predictable outcome in the final tissue architecture
for pontic and implant areas before the endosteal implants are inserted.
Patient and clinician can evaluate success and limitations prior to
implant placement. It may also shorten the time required for tissue
contouring with implant provisional restorations.
Optimal esthetics for implant therapy could be achieved by proper
3-dimensional planning, ideal implant depth in relation to adjacent
teeth and peri-implant soft tissue molded by the provisional
prosthesis.10,11 Immediate implant placement with
provisional restoration is a common procedure in which the goal is to
stablish an ideal emergence profile with maximum tissue volume,
preserving mid-facial gingiva and enhancing patient comfort and
acceptability.12,13 This then serves as a guide for
designing and fabricating the final restoration.14However, the present report has shown that all these goals could be
achieved on pontic and implant sites before the implants are inserted.
After soft tissue is ideally as described in this report, it would be
possible to perform flapless implant placement. This is suitable for
patients with sufficient keratinized gingival tissue and bone volume in
the implant recipient site. It has been reported that flapless implant
placement approach minimizes post-operative peri-implant tissue loss,
and therefore reduces the difficulties of the soft tissue management
after the surgical intervention.15 In addition,
flapless implant approach may cause less traumatic surgery, decreases
operative time, provides faster postsurgical healing and fewer
complications after surgery, and provides more comfort to the
patient.16,17 However, implanting through the prepared
soft tissue risks damaging the prepared areas, rendering the prior
treatment meaningless. If a flap is used, a very simple secondary
operation to create a hole for the implant is sufficient, reducing the
potential damage to the shaped soft tissue. This has further advantages
in allowing a clear view of the surgical site,18 and
the full penetration of irrigation water to the osteotomy, preventing
thermal damage. Thus, we chose to use open flap surgery in this case,
and the results were satisfactory. Nevertheless, it would be useful to
investigate the combination of this contouring procedure with flapless
implant placement to determine the best overall technique.
The design of the flap used in this case was based on two main
considerations. Conventional open-flap dental implant therapy cuts the
soft tissue on a line passing through the center of the implant
location. However, in this case the incision was made around the edge of
the gingival tissue, creating a single flap that lifted off the area.
First, this avoided any damage to the shaped soft tissue that might
result from an incision passing through that area. Second, by moving the
sutured area away from the implant, it reduced the risk of infection in
the newly-placed implant while the incisions were healing. This may have
contributed to the successful outcome. However, the choice of incision
location is influenced by many factors, and this approach may not be
suitable in some cases.
Following this protocol, the clinician and patient can see the future
final tissue contour in the pontic sites before implant placement. This
will enable both sided to agree on an appropriate strategy to achieve
the desired esthetics if there are shortcomings in the remaining soft
tissue.