Article - Guidelines for Flapless Surgery

Transcription

ARTICLE IN PRESS
BASIC AND PATIENT-ORIENTED RESEARCH
J Oral Maxillofac Surg
xx:xxx, 2007
Guidelines for Flapless Surgery
Anthony G. Sclar, DMD*
With the introduction ofi n-office cone beam computed tomography (CT), improved access to conventional CT scanning, and dental implant treatment planning software allowing on-the-spot 3-dimensional
evaluations of potential implant sites, the use of “flapless” implant surgery has gained popularity among
surgeons. Although the flapless approach was initially suggested for and embraced by novice implant
surgeons, the successful use of this approach often requires advanced clinical experience and surgical
judgment. This article reviews the advantages and disadvantages of and indications and contraindications
for flapless dental implant surgery, with special emphasis on requirements for establishing or maintaining
long-term health and stability of the peri-implant soft tissues. Prerequisites for surgeons wishing to use
the flapless tissue punch approach in dental implant surgery are outlined and put into perspective
relative to conventional open-flap surgery techniques and other minimally invasive procedures currently
used in implant surgery. Procedures for single- and multiple-tooth applications are illustrated.
© 2007 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg xx:xxx, 2007
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tional CT scanning, and new dental implant treatment
planning software allowing 3-dimensional evaluation
of potential implant sites, the use of flapless surgery
for implant placement has been gaining popularity
among implant surgeons. In its simplest form, flapless
surgery involves using a tissue punch device to gain
access to the alveolar ridge for implant placement or
abutment connection (Fig 2). Although the flapless
approach was initially suggested for and embraced by
novice implant surgeons, the successful use of this
approach often requires advanced clinical experience
and surgical judgment.
Although flapless implant surgery has numerous
advantages, including preservation of circulation, soft
tissue architecture, and hard tissue volume at the site;
decreased surgical time; improved patient comfort;
and accelerated recuperation, allowing the patient to
resume normal oral hygiene procedures immediately
after, the approach does have some drawbacks. Some
of these include the surgeon’s inability to visualize
anatomic landmarks and vital structures, the potential
for thermal damage secondary to reduced access for
external irrigation during osteotomy preparation, the
increased risk of malposed angle or depth ofi mplant
placement, a decreased ability to contour osseous
topography when needed to facilitate restorative procedures and to optimize soft tissue contours, and,
most importantly, the surgeon’s inability to manipulate soft tissues to ensure circumferential adaptation
of adequate dimensions of keratinized gingival tissues
around emerging implant structures.
As such, there are certain prerequisites for surgeons wishing to use the flapless approach for im-
Some of the earliest applications of the “flapless”
approach in dental implant surgery involved innovative site preservation techniques developed for immediate or delayed implant placement after tooth extraction in areas of high esthetic concern. The rationale
for the flapless approach in these case scenarios was
to isolate the implant and/or grafted socket from the
oral cavity obtaining an inclusive guided bone regeneration effect while preserving circulation and esthetic soft tissue contours. 1 This was a radical departure from the then strongly supported concept of
isolating implants placed into fresh extraction sockets
with a barrier membrane and primary flap closure. 2 In
addition, mounting clinical experience demonstrated
that esthetic hard tissue contours were also maintained by using minimally traumatic extraction techniques and substitution bone graft materials. This approach yielded predictable results even in the most
challenging case scenarios with multiple contiguous implants placed in areas of high esthetic concern ( Fig 1).
With the introduction of-in office cone beam computed tomography (CT), improved access to conven*Director of Clinical Research and Postgraduate Dental Implant
Surgery, Department of Oral and Maxillofacial Surgery, College of
Dental Medicine, Nova Southeastern University, Fort LauderdaleDavie, FL.
Address correspondence and reprint requests to Dr. Sclar: South
Florida OMS, 7600 Red Road, Suite 101, Miami, FL 33143; e-mail:
anthonysclar@aol.com
© 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/xx0x-0$32.00/0
doi:10.1016/j.joms.2007.03.017
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GUIDELINES FOR FLAPLESS SURGERY
FIGURE 1. Replacement o ailing maxillary incisors with multiple adjacent implants using a
s approach. A and B, Preoperative radiographs
demonstrating maxillary incisors with unfavorable root morphology and moderate horizontal bone loss. C , Three adjacent 1-piece nonsubmerged
implants (Straumann USA, Andover, MA) were placed with the Bio-Col ridge preservation technique immediately after
s tooth removal
facilitated by the use of periotomes.D and E, Postoperative radiographs documenting ideal placement of 3 adjacent implants and the lack of
t surgical and restorative dimension to allow placement of a fourth implant. (Figure 1 continued on next page.)
Anthony G. Sklar. Guidelines for Flapless Surgery. J Oral Maxillofac Surg 2007.
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ANTHONY G. SKLAR
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FIGURE 1 (cont’d).
F, Three-month postoperative view showing that the
s approach combined with the early tissue molding provided by
Esthetic Plus abutments (Straumann USA, Andover, MA) resulted in preservation of esthetic soft tissue volume and contours. The implant sites are ready
for provisional restoration.G , One year postdelivery of
l restoration (18 months postimplant placement) demonstrates that under
circumstances, multiple adjacent implants can be successfully used in areas of high esthetic concern.
plant placement and uncovering procedures. These
include in-depth knowledge of the criteria for optimal
p designs used in dental implant surgery, as well as
the clinical goals for surgical management of periimplant soft tissues. The surgeon should also be
knowledgeable regarding the indications and techniques (soft tissue surgical maneuvers) commonly required for successful management of peri-implant soft
tissues during conventional open p surgery. Finally,
the surgeon should be familiar with other available
minimally invasive techniques that incorporate abbreviated incisions and
, as well as pouch and tunnel
dissections, because these approaches may be more
l than the
s tissue punch approach in
many clinical scenarios.
A m grasp of the information just outlined, combined with clinical experience, with will allow the
implant surgeon to put
s surgery in proper
perspective relative to conventional
p surgery
and other minimally invasive approaches. To begin
with, the surgeon should be familiar with the following criteria for optimal p designs used in dental
implant surgery: (1) preserve circulation and alveolar
ridge topography; (2) provide access for required
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FIGURE 2. Tissue punch devices for flapless implant surgery. Handheld punch (Uni-Punch; Premier Medical, King of Prussia, PA) and
rotary tissue punch (Salvin Dental Specialties, Charlotte, NC) devices
are available in multiple diameters corresponding to commonly available implant diameters.
implant instrumentation; (3) allow identification of
vital structures; (4) provide access for modifying osseous contours and/or local bone harvest when indicated; (5) provide for closure away from submerged
fixture installation or augmentation sites; (6) minimize postsurgical bacterial contamination; (7) facilitate flap elevation, retraction, and wound closure; and
(8) aid in achieving circumferential adaptation of
good-quality tissues around emerging implant structures. 3 Although Brånemark et al 4 originally advocated using flaps incorporating vestibular incisions,
buccal flaps initiated with pericrestal incisions have
been shown to provide a practical and effective approach to implant placement, abutment connection,
and ancillary grafting procedures. 3 Typically, the buc cal flap is outlined by a pericrestal incision and 1 or
more vertical releasing incisions located at the mesial
and distal extent of the site. The surgeon simply
adjusts the position and bevel of the pericrestal incision to accommodate for submerged or nonsubmerged implant placement and abutment connection
procedures.
The implant surgeon also must be familiar with the
clinical goals and guidelines for surgical management
of peri-implant soft tissues. The clinical goal of this
surgical management is to establish an adequate zone,
approximately 3.0 mm in apicocoronal dimension
(width), of attached nonmobile, preferably keratinized, soft tissue that is circumferentially adapted to
the transmucosal implant structures. 3 Doing so provides the epithelial and connective tissue elements
needed for soft tissue integration and the development of circumferential biological width without sacrificing the underlying peri-implant supporting bone. 5
Although long-term success is possible with less than
the recommended 3.0 mm of keratinized tissue surrounding an implant restoration, predictability is far
greater with the recommended amount, because the
tissues are better able to withstand the trauma of
prosthetic procedures, abutment connection, and reconnection; the forces of mastication and oral hygiene maintenance; and the mechanical challenges
presented by removable implant prosthesis secured
by resilient prosthetic attachments.
Nevertheless, it is also important for the surgeon to
recognize that tissue thickness plays a significant role
in surgical decision making with regard to the selection of appropriate soft tissue surgical maneuvers during implant surgery and determination of when soft
tissue augmentation is needed to prevent progressive
tissue recession. Long-term clinical observations indicate that ideal tissues thickness is somewhere between 2.5 and 3.0 mm, and that the presence of
adequate soft tissue thickness greatly contributes to
the maintenance of a stable peri-implant soft tissue
environment. In addition, the combination of adequate soft tissue thickness and apicocoronal dimension of keratinized tissue surrounding an implant restoration helps resist recession, protects peri-implant
crestal bone levels, and provides esthetic masking of
underlying metal components. Furthermore, at the
ideal tissue thickness, a reduction in the apicocoronal
width of keratinized tissue may become acceptable.
Finally, in areas of high esthetic concern, along with
the objectives outlined earlier, preservation or reconstruction of esthetic soft tissue contours is required to
ensure that the peri-implant gingival tissues are in
harmony with the soft tissues surrounding the adjacent natural dentition in terms off orm, color, and
surface texture. In many cases, this requires greater
apicocoronal dimensions of keratinized gingival tissues than recommended earlier.
Another prerequisite for implant surgeons desiring
to perform flapless implant surgery includes awareness of the indications and the surgical technique
(soft tissue surgical maneuvers) commonly used for
successful management of peri-implant tissues.3
When placing a nonsubmerged implant or performing
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ANTHONY G. SKLAR
Table 1. GUIDELINES FOR SELECTING SOFT TISSUE
SURGICAL MANEUVERS
Width of Keratinized
Gingiva Present on
Buccal Flap Margin
Indicated Surgical Maneuver
5 to 6 mm
4 to 5 mm
3 to 4 mm
Resective contouring
Papilla regeneration (Palacci)
Lateral flap advancement
abutment connection to a submerged implant, optimal flap design dictates locating the pericrestal incision such that approximately 3.0 mm of good-quality
keratinized tissue remains on the oral aspect of the
emerging implant structures. Then the apicocoronal
dimension (width) of the keratinized gingival remaining on the elevated buccal flap guides the surgeon in
selecting the appropriate surgical maneuver for that
particular site, keeping in mind the need to obtain a
circumferential adaptation of approximately 3.0 mm
of keratinized tissue surrounding the emerging implant (Table 1).
Resective contouring (gingivectomy) is indicated
when the apicocoronal dimension of keratinized gingival remaining on the buccal flap adjacent to the
implant site is 5 to 6 mm ( Fig 3). Typically, the
surgeon begins by passively aligning the flap adjacent
to implant abutment at one end of the surgical site
and uses a low-profile scalpel (eg, a 15c blade) to
perform the resection. The flap is then secured mesial
and distal to that abutment with interrupted sutures.
Next the surgeon evaluates the width of tissue at the
adjacent sites and, ifi ndicated, sequentially performs
the resective contouring maneuver at each site and
secures the flap to obtain circumferential tissue adaptation around the remaining abutments (Figs 3B,C).
The papilla regeneration technique, as originally
described by Palacci, 6 is indicated when 4 to 5 mm of
keratinized tissue remains on the buccal flap margin
adjacent to the implant site in question. This technique is very useful for obtaining circumferential closure of good-quality tissue around the emerging im-
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FIGURE 3. Resective contouring. A, When apicocoronal dimension of keratinized tissue remaining on the buccal flap is between 5 and 6 mm,
the resective contouring maneuver is used to obtain circumferential tissue closure around the emerging implant neck or abutment. After outlining the
flap, tissue is taken from the top of the ridge and moved in a buccal direction. B, A 15c scalpel is used to precisely perform the gingivectomy adjacent
to the emerging implant neck, after which the tissue is adapted around the abutment and, if appropriate, the resection is repeated sequentially
adjacent to each implant site.C, The contoured flap is then apically repositioned and secured around each emerging implant with sutures placed
in the interimplant areas. (Reprinted with permission.3 )
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FIGURE 4. Papilla regeneration. A, When apicocoronal dimension of keratinized tissue remaining on the buccal p is between 4 and 5 mm,
the papilla regeneration maneuver is indicated to obtain circumferential tissue closure around the emerging implant neck or abutment. After outlining
the
, tissue is taken from the top of the ridge and moved in a buccal direction. Pedicles that correspond to the interimplant spaces are then created
in the margin of the p using a
e scalpel. B,The pedicles are then rotated into the interimplant space. A “reverse cutback” facilitates passive
rotation of the pedicle without embarrassing its circulation. C , After adapting the
,
8 or interrupted sutures are used to obtain circumferential
tissue closure around the emerging implants. (Reprinted with permission.3 )
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plant structures ( Fig 4A). The use of this technique
also promotes the formation of an interimplant papilla
when adequate bone support is present and ideal
spacing between implants has been achieved. In a
fashion similar to the resection maneuver, the surgeon passively aligns the p adjacent to the implant
abutment and places light pressure near the p margin with his or her
r tip after, then uses a lowe blade to create a pedicle in the margin of the
p in such a fashion to allow passive rotation into
the adjacent interdental or interimplant space ( Fig
4B). The p is then secured with
8 or simple
interrupted sutures in a fashion that avoids tension in
the pedicle, which could embarrass its circulation
causing necrosis ( Fig 4C).
Lateral p advancement is the indicated surgical
maneuver when only 3 to 4 mm of keratinized tissue
width remains on the buccal p ( Fig 5A). To
from this soft tissue maneuver, the pericrestal incision
must be extended well beyond the area o mplantation, to allow lateral advancement of keratinized tissue into the implant site (Figs 5A,B). The p is then
secured with interrupted sutures, typically resulting
in exposure of alveolar bone distal or mesial to the
site. Closure at the areas of bone exposure is obtained
through mucosal advancement, or, in some cases, a
protective dressing is applied in this area ( Fig 5C). In
Kennedy class III situations, the
p is extended
through split-thickness dissection to allow advancement of a portion of the keratinized tissue present
around the adjacent natural dentition into the implant
site without encroaching on the marginal gingival
tissues. Preoperative assessment allows the surgeon
to determine whether
t apicocoronal dimension of keratinized tissue is present around the adjacent dentition to allow for this.
When the apicocoronal dimension of keratinized
tissue surrounding an implant restoration is or will be
3.0 mm, the surgeon should consider using soft
tissue augmentation procedures to provide for longterm stability. The propensity for progressive periimplant soft tissue recession is multiplied when inadequate tissue thickness is combined with reduced
keratinized tissue width at a particular site.
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ANTHONY G. SKLAR
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FIGURE 5. Lateral p advancement.A, When the apicocoronal dimension of keratinized tissue remaining on the buccal p is between 3 and
4 mm, resective maneuvers may result in less than the ideal soft tissue dimensions required to establish a stable hard and soft tissue peri-implant
environment. Instead, the lateral p advancement maneuver is used to obtain circumferential tissue closure around the permucosal implant
components. After outlining a p that extends well beyond the planned implant surgery site, tissue is taken from the top of the ridge and moved in
a buccal direction. B and C , The resultant p is apically repositioned and adapted around the emerging implant structures and, in most instances,
the closure begins at the anterior most implant and progresses distally with sutures placed in the interimplant areas. As a consequence, the keratinized
tissues are advanced into the implant surgery site from adjacent areas. (Reprinted with permission. )3
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Along with having in-depth knowledge of the clinical goals, guidelines, and surgical techniques used for
successful management of peri-implant soft tissues,
the implant surgeon also should be familiar with other
minimally invasive approaches for implant placement,
exposure, and grafting, such as U-shaped peninsula
s (Fig 6), abbreviated trapezoidal
, and pouch
or tunnel dissections, which can have advantages
comparable to those of the
s tissue punch approach with improved access and visualization ( Figs 7
and 8). 3 Furthermore, the surgeon should consider
using instrumentation that minimizes tissue trauma
and helps preserve soft tissue volume, which is in
concert with the underlying concept of minimally
invasive surgery. High-frequency (4 MHz) radio surgery instrumentation allows the implant surgeon to
maintain a relatively “bloodless”
d during minimally invasive procedures, thus maximizing intraoperative visibility ( Fig 9). This provides a
intraoperative for surgeons performing implant surgery and adjunctive procedures through the mini-
mally invasive approaches described earlier. In addition, this technology allows the surgeon to perform
very e incisions in precise locations with negligible
lateral tissue damage, resulting in maximum tissue
preservation at the site. 7
Finally, armed with the necessary prerequisites outlined earlier, the surgeon can take full advantage of
the
s approach in dental implant surgery. The
s (tissue punch) approach is indicated when
the surgeon has
e that the underlying osseous anatomy is ideal relative to the planned implant
diameter and 3-dimensional placement in the alveolus. Typically, this is determined by clinical and radiographic evaluation, aided by analysis of articulated
dental study models. Nevertheless, interactive CT
treatment planning is of great
t for evaluating
osseous ridge morphology in a
t percentage
of cases. In cases where site preservation is performed at the time of tooth removal, the surgeon
should closely observe and document the dimensions
of the remaining alveolar housing and the morphol-
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of good-quality soft tissues will remain surrounding the
emerging implant structures for optimal function and
esthetics. To minimize soft tissue complications that can
jeopardize the long-term success of an implant restoration, the quantity, quality, and position of the existing
keratinized tissues relative to the planned implant emergence should be evaluated before surgery.3 This evaluation is facilitated by a preoperative try-in of the surgical
template, allowing the surgeon to determine whether
adequate apicocoronal width of keratinized tissue will
remain after a tissue punch procedure to establish a
stable peri-implant soft tissue environment, as discussed
earlier. To make this determination, the implant surgeon
must be familiar with the criteria for optimal flap designs
used for implant placement and exposure as outlined
earlier ( Fig 10). When these criteria are not met, the
flapless approach is contraindicated ( Fig 11). Finally,
when unexpected intraoperative findings necessitate additional access or visualization, the surgeon must be
prepared for the appropriate course of action ( Fig 12).
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References
FIGURE 6.
The U-shaped peninsula flap. This flap provides the
advantages of tissue preservation and patient comfort associated
with the flapless tissue punch approach with enhanced visualization
of osseous anatomy during implant surgeries. (Reprinted with
permission.3 )
ogy of any socket wall defects. This information will
allow the surgeon to decide whether a flapless approach will be feasible for subsequent implant placement in most cases when delayed implant placement
is planned after the tooth extraction.
Most importantly, as outlined earlier, the surgeon also
must be able to determine whether an adequate volume
1. Sclar AG: Preserving alveolar ridge anatomy following tooth
removal in conjunction with immediate implant placement: The
Bio-Col technique. Atlas Oral Maxillofac Surg Clin North Am
7: , 1999
2. Lazzara RJ: Immediate implant placement into extraction sites:
Surgical and restorative advantages. Int J Periodont Rest Dent
9:333, 1989
3. Sclar AG: Surgical techniques for management of peri-implant
soft tissues. In : Soft Tissue and Esthetic Considerations in Implant Therapy. Chicago, IL, Quintessence, 2003, p 43
4. Branemark P-I, Zarb GA, Albrektsson T: Tissue-Integrated Prostheses: Osteointegration in Clinical Dentistry. Chicago, IL, Quintessence, 1985, p 211
5. Berglundh T, Lindhe J: Dimension of the peri-implant mucosa:
Biologic width revisited. J Clin Periodontol 23:971, 1996
6. Palacci P, Ericsson I, Engstrand P, et al: Optimal Implant Positioning and Soft Tissue Management for the Brånemark System.
Chicago, IL, Quintessence, 1995, p 59
7. Niamtu J: 4.0-MHz radiowave surgery in cosmetic facial surgery.
Australas J Cosmetic Surg 1:52, 2005
8. Sclar AG: The Bio-Col technique. In : Soft Tissue and Esthetic
Considerations in Implant Therapy. Chicago, IL, Quintessence,
2003, p 75
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FIGURE 7. Abbreviated flap-pouch procedure.A, An abbreviated flap is outlined by incisions that are beveled toward the center of the site that
end at the mucogingival junction.B, After subperiosteal elevation of the abbreviated flap, surgical access and visualization is enhanced by extending
the dissection further apically (pouch dissection), allowing a guided bone regeneration procedure to be performed to repair a fenestration defect.
C , The beveled portions of the flap are precisely readapted and simple interrupted sutures are used for closure at both lateral incisor sites. D, By
combining an abbreviated flap with a subperiosteal pouch, an ideal esthetic result was obtained. This minimally invasive approach provided access
for performing the guided bone regeneration procedure without extensive flap elevation that can result in flap retraction and soft tissue shrinkage.
The papillary sparing beveled incisions resulted in inconspicuous incision lines and maintenance of scalloped soft tissue architecture.
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FIGURE 8.
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ANTHONY G. SKLAR
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FIGURE 8. Use of minimally invasive procedures for esthetic implant replacement off ractured central incisor and repair of associated labial bone
and soft tissue recession defects. (Reprinted with permission.8)A, Preoperative frontal view demonstrated tissue inflammation and discoloration
resulting from tooth fracture and tooth mobility. Soft tissue shrinkage is expected after tooth removal despite use of ridge preservation. B, Preoperative
radiograph demonstrating widened periodontal ligament space and apical radiolucency. C, Types ofl abial bone defect after tooth removal.
Whereas labial bone defects whose widths are 1/3 the width of the site or less have a favorable prognosis of regeneration when site preservation
procedures are performed, those wider than 1/3 of the width of the site have an unfavorable prognosis despite site preservation. The defect in this
case had a favorable morphology. D, A pouch procedure was used to dissect in a subperiosteal plane extending 2.0 mm beyond the periphery
of the defect. An absorbable collagen membrane (Bio-Gide; Osteohealth, Oceanside, NY) was carefully positioned within the pouch after which
Bio-Oss anorganic bovine bone mineral was condensed in the extraction socket. This creates a “tenting” effect of the periosteum overlying the labial
bone defect. The membrane was folded over the occlusal portion of the porous bovine mineral graft and an absorbable collagen dressing (CollaPlug;
Zimmer Dental, Carlsbad, CA) was placed to further isolate the site, support the supraosseous soft tissues, and to promote rapid connective tissue
in growth and epithelialization of the site. Iso-butyl cyanoacrylate tissue cement (IsoDent; Ellman International, Oceanside, NY) was then placed over
the collagen dressing to render the site impervious to oral liquids. E, The postextraction site preservation radiograph. F, Four months after tooth
removal, flapless implant placement was facilitated using a rotary tissue punch. Sharp dissection was used to create a supraperiosteal pouch, which
served as a recipient site for a subepithelial connective tissue graft harvested from the maxillary tuberosity. G and H, Smile and close-up fontal views
of the implant restoration 18 months after delivery of the final restoration. Flapless tooth extraction and delayed implant placement combined with
minimally invasive pouch approaches for repair of the favorable labial bone defect and subsequent soft tissue reconstruction yielded an excellent
esthetic result in this case of high esthetic concern.
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FIGURE 9. Application of 4-MHz radio surgery in minimally invasive
dental implant surgery. The 4-MHz radio surgery technology (Surgitron; Ellman International, Oceanside, NY) allows the surgeon to
perform incisions with minimal heat dissipation and cellular alteration.
Very fine incisions can be precisely located adjacent to implant abutments without the risk of unanticipated soft tissue recession. The relatively bloodless surgical field achieved using this instrumentation provides a tremendous advantage for surgeons performing minimally
invasive dental implant surgery.
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ANTHONY G. SKLAR
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FIGURE 10. Application of the flapless approach for implant replacement of a failing mandibular molar. A , Preoperative radiograph of a failing
mandibular molar. The patient had experienced continued sensitivity after completing endodontic therapy over a 2-year period. Note the
radiolucency in the interradicular area indicating a chronic inflammatory process most likely associated with bacterial ingress. B, Three months
postextraction with site preservation with the Bio-Col technique, the location and apicocoronal dimension of keratinized tissue at the site is ideal for
placement of the implant through a flapless approach. C, One week post-flapless implant placement. Peri-implant tissue health is ideal, and the
papillary and col anatomy have been preserved. Note that adequate apicocoronal dimension of keratinized tissue surround the implant despite the
tissue punch procedure. Accelerated healing and improved postoperative oral hygiene are evident. D and E, Clinical and radiographic views 1 year
postdelivery of the final restoration. The flapless approach for tooth extraction, site preservation, and subsequent implant placement preserved the
hard and soft tissue ridge contours facilitating the delivery of an implant restoration that is functional, self-cleansing, and esthetically pleasing. Note
the complete resolution of preexisting radiolucency and maintenance ofi deal crestal bone levels.
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FIGURE 11.
Determining whether flapless surgery is indicated for implant placement. A, Preoperative try-in of surgical template indicated that
the flapless approach was contraindicated at the first molar implant site. Nevertheless, during surgery, a round bur was used to mark the center of
the implant osteotomy by penetrating through the soft tissues at the ridge crest before elevation of the abbreviated flap seen here. The location of
the soft tissue puncture clearly demonstrates that the use of a 6.0-mm tissue punch would have excised all the keratinized tissue buccal to the emerging
first molar implant. Note that a tissue punch approach would have been feasible for the second molar site. B, In this case, ideal tissue thickness
allowed the use of a variation of the papilla regeneration maneuver. The pedicles were created in the lingual flap and passively rotated into the
interimplant space. C , A simple interrupted suture was used to secure the abbreviated buccal flap mesial and distal to the emerging first molar implant
and a horizontal mattress suture was used to secure the lingual pedicles in the inter-implant space without embarrassing their circulation. Note the
6.0-mm margin of apicocoronal keratinized tissue present on the buccal flap adjacent to the second molar implant. D, Resective contouring was
performed at the second molar site with a 15c blade, and a simple interrupted suture was used to secure the flap distal to the second molar implant.
E, Three-year follow-up clinical photograph demonstrating a stable and self-cleansing peri-implant soft tissues environment as a result of appropriate
flap design and use of surgical maneuvers to create scalloped soft tissue contours that resist collection off ood debris.
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ANTHONY G. SKLAR
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FIGURE 12. Use of minimally invasive tunnel dissection to provide access for repair an osseous fenestration defect occurring unexpectedly during
s implant placement.A, Occlusal view of
s placement o mplant (Prevail; 3i Biomet, Palm Beach Gardens, FL) after use of a rotary tissue
punch and a series of twist and
e drills. Unexpectedly, a fenestration defect was detected by palpation over the apical aspect of the surgical
site. B and C , A full-thickness vertical incision was performed 5.0 mm mesial to the fenestration defect and a subperiosteal tunnel was made 5.0
mm distal to the defect. Grafting was accomplished through this minimally invasive approach using autogenous bone and porous bone mineral
(Bio-Oss; Osteohealth, Shirley, NY). The resorbable barrier membrane (Ossix Plus; 3i Biomet) shown in this photograph was introduced into the tunnel
and stabilized by absorbing blood at the site with light pressure held over the graft site for 10 minutes. Interrupted sutures were then used for closure.
D, Postoperative periapical radiograph demonstrates ideal implant positions as per surgical guide. Seating of abutments through the tissue punch
access is facilitated by the integrated platform-switching feature of the implants used in this case (Prevail; 3i Biomet). E, Postoperative cone beam
CT cross-sectional image (I-Cat Vision Software; Imaging Sciences International,
, PA) of the grafted defect indicating successful augmen tation of the defect and surrounding thin buccal plate visualized through the subperiosteal tunnel.
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Article - Guidelines for Flapless Surgery

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