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.