Hard and soft tissue augmentation of vertical ridge defects with the “hard top double membrane technique”: introduction of a new technique and a case report

<abstract> <p>Vertical ridge defects (VRD) of the jaws often require both bone and keratinized mucosa (KM) reconstruction. A new staged procedure is proposed to restore both hard and soft tissues in the VRD through a case report. A patient required the lower right second premolar and first molar rehabilitation. The first surgery aimed to restore the bone architecture through the use of a titanium reinforced dense-PTFE (TR-dPTFE) membrane, positioned and stabilized on top of tenting screws. This membrane didn't cover the whole defect, it just created an hard top that avoided the collapse of a collagen membrane that was placed over it. This resorbable membrane was stabilized with tacks and covered the whole defect, protecting a mixture of autogenous bone and porcine xenograft both lingually and buccally. The second surgery was performed after a 5 month healing time either to remove the tenting screws and the TR-dPTFE membrane, and to augment KM with a gingival graft harvested from the palate. Both regenerated hard and soft tissues were left to mature for 7 months before the third surgery. In this last stage implants insertion and healing abutments application were carried out in a straightforward way, since bone and KM had been previously restored. Two bone samples, harvested for histologic evaluation, stated a great amount of new bone formation. This new approach allowed inserting implants in matured and stable regenerated bone and augmented KM, avoiding the hard and soft tissue loss around implant neck that can affect the VRD treatments during healing.</p> </abstract>

Peri-Implant Soft Tissue Augmentation

The peri-implant soft tissue (PIS) augmentation procedure has become an integral part of implant-prosthetic rehabilitation. Minimal width of keratinized mucosa (KM) of 2 mm is deemed necessary to facilitate oral hygiene maintenance around the implant and provide hard and soft peri-implant tissue stability. PIS thickness of at least 2 mm is recommended to achieve the esthetic appearance and prevent recessions around implant prosthetic rehabilitation. The autogenous soft tissue grafts can be divided into two groups based on their histological composition—free gingival graft (FGG) and connective tissue graft (CTG). FGG graft is used mainly to increase the width of keratinized mucosa while CTG augment the thickness of PIS. Both grafts are harvested from the same anatomical region—the palate. Alternatively, they can be harvested from the maxillary tuberosity. Soft tissue grafts can be also harvested as pedicle grafts, in case when the soft tissue graft remains attached to the donor site by one side preserving the blood supply from the donor region. Clinically this will result in less shrinkage of the graft postoperatively, improving the outcome of the augmentation procedure. To bypass the drawback connected with FGG or CTG harvesting, substitutional soft tissue grafts have been developed.

Optiminization of regeneration at the stages of soft tissue augmentation using a collagen matrix

Lack of adequate width and thickness of periodontal or peri-implant soft tissues can compromise the aesthetics, function or survival of teeth and dental implants. Biomaterials are widely used in dentistry to overcome the disadvantages of autogenous tissue transplantation. The advantage of using biomaterials is that there is no need for re-surgery and that they are available in large quantities. The most widely used biomaterial for soft tissue augmentation is collagen, as it is believed to best mimic the natural cellular environment of the extracellular matrix, although other biomaterials are also candidates for soft tissue regeneration. Collagen matrices differ in composition, three-dimensional structure, elasticity and mechanical stability. Aim. is to review the literature on the optimization of regeneration at the stages of soft tissue augmentation using a collagen matrix.

Secondary Treatment of Facial Asymmetry in Hemifacial Microsomia

Hemifacial microsomia is most often diagnosed at birth and comprises varying degrees of malformations of one side of the face. Depending on the malformations involved, multiple procedures are required as primary treatment approaches, often embedded in an interdisciplinary concept from birth to adolescence. However, with regard to the symmetry of the face, soft tissue and bony discrepancies between the normal and the affected side often remain recognizable or even persist after surgery, resulting in lasting disturbed facial harmony. Such patients may have a high burden of disease. In our case report, we present the clinical course of a 39-year-old female with hemifacial microsomia, who was suffering persistent facial asymmetry after primary treatment comprising surgery on the mandible and soft tissue augmentation with the use of a free muscle flap. By means of virtual planning tools and patient-specific implants for genioplasty and bony augmentation in a first step followed by soft tissue augmentation with autologous fat cells in a second step, a very satisfactory result was achieved for both patient and medical staff. Hence, for secondary treatment of facial asymmetry in adulthood, a combined and step-by-step therapy addressing both soft and hard tissue seems to be the key to success.

Hard and Soft Tissue Augmentation with Single-Implant Restoration in the Esthetic Zone

The removal of the central incisor of the upper jaw is a challenging process, since the restoration of a single implant in the esthetic zone is of great responsibility. When tooth extraction with immediate implant placement is not possible, modern protocols imply the use of the socket preservation technique. This method of preserving socket properties significantly reduces changes that occur during the healing process of the postextracted area and along with soft tissue augmentation allows to achieve a satisfying aesthetic result. The aim of present case report is to assess capabilities of socket preservation concept and application of soft tissue augmentation in the anterior maxillary region. The treatment steps of a 35-year-old woman who needed to remove tooth 11 with further dental implant placement are described. The clinical case is of interest because after socket preservation and soft tissue augmentation, an acceptable aesthetic result was not reached. However, additional soft tissue augmentation made it possible to achieve the desired result, which was stable for 7 years.