Accepted Manuscript Use of Transalveolar Sutures to Maintain Vestibular Depth and Keratinized Tissue Following Alveolar Ridge Reduction and Implant Placement for Mandibular Prosthesis George R. Deeb, DDS, MD Janina Golob Deeb, DDS, MS Daniel M. Laskin, DDS, MS Vickas Agarwal, BS PII:
S0278-2391(14)01236-1
DOI:
10.1016/j.joms.2014.07.022
Reference:
YJOMS 56426
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 20 May 2014 Revised Date:
15 July 2014
Accepted Date: 21 July 2014
Please cite this article as: Deeb GR, Deeb JG, Laskin DM, Agarwal V, Use of Transalveolar Sutures to Maintain Vestibular Depth and Keratinized Tissue Following Alveolar Ridge Reduction and Implant Placement for Mandibular Prosthesis, Journal of Oral and Maxillofacial Surgery (2014), doi: 10.1016/ j.joms.2014.07.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Use of Transalveolar Sutures to Maintain Vestibular Depth and Keratinized Tissue Following Alveolar Ridge Reduction and Implant Placement for Mandibular Prosthesis
RI PT
George R. Deeb, DDS, MDa, Janina Golob Deeb, DDS, MSb, Daniel M. Laskin, DDS, MSc and Vickas Agarwal, BSd
a
SC
Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, 521 North 11th Street, Richmond 23298 b
M AN U
Assistant Professor, Department of General Practice, School of Dentistry, Virginia Commonwealth University, 521 North 11th Street, Richmond 23298
c
Professor Emeritus, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, 521 North 11th Street, Richmond 23298 Student, School of Dentistry, Virginia Commonwealth University, 521 North 11th Street, Richmond 23298
AC C
EP
TE D
d
ACCEPTED MANUSCRIPT
Use of Transalveolar Sutures to Maintain Vestibular Depth and Keratinized Tissue Following Alveolar Ridge Reduction for Implant Placement for Mandibular Implant Prosthesis
RI PT
George R. Deeb DDS, MD, Janina Golob Deeb DDS, MS, Daniel M. Laskin DDS, MS and Vickas Agarwal BS
M AN U
SC
Reconstruction of the totally edentulous patient with dental implants has become a routine treatment with predictable outcomes. Firm keratinized tissue surrounding the implants and adequate vestibular depth are among the determining factors for long-term implant success. In the staged approach of mandibular implant reconstruction, adequate vestibular depth as well as attached gingiva surrounding the implants can be readily established at the time of implant placement or when the implants are uncovered. However, in cases when extractions and necessary mandibular ridge reduction to create adequate width are done immediately prior to implant placement, maintaining adequate keratinized tissue around the implants, as well as preventing prolapse of the vestibule, can present a challenging situation. The aim of this report is to present a technique that allows the surgeon to stabilize the vestibular depth and at the same time position the flaps around the implants to preserve the attached gingiva.
TE D
Technique
AC C
EP
A mid-crestal incision is performed in edentulous areas and a sulcular incision is used to release the gingiva around the remaining teeth. Full thickness mucoperiosteal flaps are released on facial and lingual aspects extending bilaterally between the first molar sites or to the distal of extracted teeth. The extractions are done as atraumatically as possible, followed by bicortical mandibular alveolar reduction to the predetermined level and routine implant placement (Figure 1). The amount of bone reduction necessary for prosthetic height, as well as mandibular width to contain the implants, is determined on the preoperative cone beam CT by measuring from the incisal edge of the remaining teeth. After implant placement, a straight fissure bur is used to make transalveolar channels in the alveolar bone between implants starting on the outer facial surface and through lingual aspect of the mandible. Alternatively, only perforation of the lingual cortical bone may be used in cases where vestibular depth is not as critical as positioning the tissue drape apically and controlling the zone of keratinized tissue (Figure 2). The osteotomies are positioned up to 5 mms apical to the height of the alveolar ridge or just apical to it, depending on the amount of vestibular depth required (Figure 5). The number of osteotomies for transalveolar fixation sutures depends on the number of implants placed and the distance between them.
ACCEPTED MANUSCRIPT
RI PT
Once the osteotomies for channels have been completed, a 3.0 polyglactic suture on a minimally curved needle is introduced through the facial flap before entering into the transalveolar channel and then engaging the lingual flap upon exiting (Figure 3). The excess mucosa is not excised. After all of the sutures have been placed, a triple knot is tied to closely adapt the flaps to the underlying bone and to secure the keratinized tissue around the implants on both the lingual and facial aspects (Figure 4). Wound closure is completed by suturing the mucosal margins with interrupted sutures (Figure 6). In case of tissue irritation, transalveolar sutures can be removed at post-operative visit once stable tissue adaptation to underlying bone is achieved (Figure 7). Discussion
M AN U
SC
Bone anchoring sutures have been described previously for adapting soft tissue around single stage dental implants1. This technique improves seating and healing of the gingival tissues, secures vestibular depth, and reduces subsequent mobility of the facial and lingual flaps in a coronal direction following mandibular implant placement1. Traditionally, unsecured flaps migrate coronally and vestibular depth and the amount of keratinized tissue surrounding the implants are compromised. For restorative purposes and plaque removal, this presents a challenge. We present several modifications to previously described technique and expand the application to immediate implant placement in conjunction with extractions, alveloplasty and alveolectomy as well as immediate implant placement and loading.
AC C
EP
TE D
With this technique, sutures are placed bisecting the inter-implant alveolar bone, thus avoiding the immediate peri-implant tissues. Ideally, there should be a transalveolar suture between each implant site, and include transalveolar sutures distally to the most distal implant site. When implant retained, tissue supported restorations, such as the two implant overdenture, are planned, suture osteotomies are placed apically up to five mm to increase vestibular depth to allow for flange extensions. When planning for completely implant supported prosthesis, such as hybrid restorations, perforation of only one cortex at the crest is utilized in order to decrease tissue prolapse and control the position of the attached gingiva. Further work to identify the ideal vestibular depth in both types of restorations is being carried out at this time and will be analyzed statistically in an IRB sanctioned study. The authors are also applying a variation of the technique to maxillary surgery and will share their results when an adequate number of cases are completed. Single stage surgery in conjunction with extractions when indicated is our preferred treatment. The reduced number of surgical procedures has many benefits for the patient. These include reduced anesthetic risks, postoperative pain and complications, as well as decreased length of overall treatment time. The success rate of the implants placed in a single stage surgery compared to the those placed with delayed uncovering has been shown to be favorable.3 Often patients experience significant atrophy of the keratinized tissue of the edentulous mandible, as well as frequent perforations over the cover screws during the healing period of buried implants.4-5 These conditions present the surgeon at the uncovering of the implants with a challenge on how to recreate the prosthetic space on both the lingual
ACCEPTED MANUSCRIPT
and buccal aspects of the implants, as well as how to restore keratinized tissue to the peri-implant regions.
RI PT
The presence of attached gingiva measuring 2 mms or less at the site of insertion has been associated with a high rate of early implant failure.6 Thin or absent gingival tissue around implants has been associated with bleeding on probing and greater loss of alveolar bone supporting the implants.8 On the other hand, having an adequate zone of gingiva around implants facilitates plaque control and the interface with prosthetic devices, and has been associated with improved long-term success and stability of implants.7
M AN U
SC
With the goal of creating a thicker band of attached gingiva around implants, a second surgical procedure is often performed before the restorative treatment phase. Free gingival grafting procedures and vestibuloplasties have been shown to produce significant postoperative discomfort and bleeding in patients.9 There is also the added challenge to increase the width of gingiva as well as the prosthetic space on the lingual aspect of implants in edentulous mandible.10 Securing both the lingual and buccal flaps apically to a fixed and stable bony anchorage greatly reduces the likelihood of prolapse of the buccal vestibule and elevation of the lingual floor into prosthetic space as well as beyond the implant margins. This fixed anchorage is especially important in patients that cannot wear prosthetic devices during the healing phase.11
TE D
Studies have confirmed that attaching healing abutments at the time of implant placement does not adversely influence the outcome of implant treatment either in regard to marginal bone loss or the health of the soft tissues around the implant.12 Single stage surgery with the placement of healing abutments actually allows the patient the additional benefit of greater prosthesis retention during the healing stage.13
AC C
EP
Evaluation of this technique so far shows that it is successful in preventing tissue overgrowth above and onto the surface of the implant following healing (Figure 7). Further, patients do not have any additional discomfort other than that associated with the implant placement itself. It is also important to note that the osteotomies made to secure the sutures were reossified within 6 months (illustrated radiographically).1,2
Conclusion
Increased postoperative complications and the prolonged treatment time associated with staged implant therapy have led to a search for improvement in stabilizing keratinized tissue and vestibular depth at the time of implant placement in the edentulous mandible, hence eliminating the need for a second surgery. The use of transalveolar sutures successfully fulfills these goals.
SC
RI PT
ACCEPTED MANUSCRIPT
References:
AC C
EP
TE D
M AN U
1. Altiparmak N, Uckan S: Bone anchoring of sutures for adequate repositioning of the soft tissue flaps in one stage dental implants. Int J Oral and Maxilllofac Surg 42:535, 2013 2. Lauer G, Schwarz U, Schilli W: Transalveolar fixation of the peri-implant soft tissue in the mandible: surgical method and clinical follow-up. J Oral and Maxillofac Surg 54:690, 1996 3. Shigerhara S, Ohba S, Nakashima K, Takanashi Y, Asahina I: Immediate loading of dental implants inserted in edentulous maxillas and mandibles; 5-year results of a clinical study. J Oral Implantol 2014. 4. Weber HP, Cochran DL: The soft tissue response to osseointegrated dental implants. J Prosthet Den 79:79, 1998 5. Cehreli MC, Kökat AM, Uysal S, Akca K: Spontaneous early exposure and marginal bone loss around conventionally and early-placed submerged implants: a double-blind study. Clin Oral Implants Res 21:1327, 2010 6. Baqain ZJ, Moqbel WY, Sawair FA: Early dental implant failure: risk factors. Br J Oral Maxillofac Surg 50:239, 2012 7. Block MS, Kent JN: Factors associated with soft- and hard-tissue compromise of endosseous implants. J Oral Maxillofac Surg 48:1153, 1990 8. Bouri A, Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I: Width of keratinized gingiva and the health status of the supporting tissues around dental implants. Int J Oral Maxillofac Implants 23:323, 2008 9. Griffin TJ, Cheung WS, Athanasios IZ, Damoulis PD: Postoperative complications following gingival augmentation procedures. J Periodontology 77:2070, 2006 10. Stimmelmayr M, Stangl M, Edelhoff D, Beuer F: Clinical prospective study of a modified technique to extend the keratinized gingiva around implants in combination with ridge augmentation: oneyear results. Int J Oral Maxillofac Implants 26:1094, 2011 11. Peñarrocha M, Boronat A, Garcia B: Immediate loading of immediate mandibular implants with a full-arch fixed prosthesis: a preliminary study. J Oral Maxillofac Surg 67:1286, 2009. 12. Watson CJ, Ogden AR, Tinsley D, Russell JL, Davison EM. A 3- to 6-year study of overdentures supported by hydroxyapatite-coated endosseous dental implants. Int J Prosthodontics 11:610, 1998
ACCEPTED MANUSCRIPT
SC
RI PT
13. Liddelow GJ, Henry PJ: A prospective study immediately loaded single implant mandibular overdentures: preliminary one-year results. J Prosthet Dent 97:126, 2007 14. Karandikar S, Bhawsar S, Varsha Murthy J, Pawar P, Yuvaraj V, Dalsingh V: Bhawsar-karandikar stent: an aid to vestibuloplasty. J Maxillofac Oral Surg 12:237, 2013
Figure Legends
M AN U
Figure 1: Five lower implants placed for an immediate loaded full arch provisional restoration. Figure 2: Close up photo of a fissure bur being used to make an inter-implant osteotomy of the lingual cortical bone as means for stabilizing flaps in an apical position. In this example the lingual cortex is being perforated due to wide bucco-lingual dimension of the alveolar ridge, as well as to avoid inadvertent damage to the implants.
TE D
Figure 3: Intraoperative photograph showing the suturing sequence. The operator will pass from the buccal tissues through the alveolus and the through the lingual tissues before tying the knot over the ridge to secure the tissues.
EP
Figure 4: Intraoperative photograph with three transalveolar sutures in place. The sutures are placed in the inter implant bone and secured. The rest of the final closure is completed in chromic gut suture. Note the preservation of keratinized tissue and apical position of the flaps.
AC C
Figure 5: Intraoperative photograph post implantation showing the needle being passed through the alveolus in order to demonstrate the placement of the transalveolar osteotomy in a 5 mm apical position. For altering vestibular height the osteotomy should be placed apically as shown. For utilization the buccal flap should be engaged before entering the osteotomy and the lingual flap upon exiting as in figure 3. Figure 6: Immediate postoperative view of the closure utilizing the transalveolar suture (arrow) securing the flaps in an apical position in order to increase vestibular depth. Figure 7: One week postoperative photo showing favorable healing and stable tissue adaptation around the implants. The transalveolar sutures (arrows) are still intact.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 1: Five lower implants placed for an immediate loaded full arch provisional restoration.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 2: Close up photo of a fissure bur being used to make an inter implant osteotomy of the ligual cortical bone as means for stabilizing flaps in an apical position. In this example the ligual cortex is being perforated due to wide bucco-lingual dimension of the alveolar ridge as well as to avoid inadvertent damage to the implants.
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Figure 3: Intraoperative photograph showing the suturing sequence. The operator will pass from the buccal tissues through the alveolus and the through the lingual tissues before tying the knot over the ridge to secure the tissues.
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
Figure 4: intraoperative photograph with three transalveolar sutures in place. The sutures are placed in the inter implant bone and secured. The rest of the final closure is completed in chromic gut suture. Note the preservation of keratinized tissue and apical position of the flaps.
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
Figure 5: Intraoperative photograph post implantation showing the needle being passed through the alveolus in order to demonstrate the placement of the transalveolar osteotomy in a 5 mm apical position. For altering vestibular height the osteotomy should be placed apically as shown. For utilization the buccal flap should be engaged before entering the osteotomy and the lingual flap upon exiting as in figure 3.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 6: Immediate postoperative view of the closure utilizing the transalveolar suture (arrow) securing the flaps in an apical position in order to increase vestibular depth.
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
Figure 7: One week postoperative photo showing favorable healing and stable tissue adaptation around the implants. The transalveolar sutures (arrows) are still intact.
S0278-2391(14)01236-1
DOI:
10.1016/j.joms.2014.07.022
Reference:
YJOMS 56426
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 20 May 2014 Revised Date:
15 July 2014
Accepted Date: 21 July 2014
Please cite this article as: Deeb GR, Deeb JG, Laskin DM, Agarwal V, Use of Transalveolar Sutures to Maintain Vestibular Depth and Keratinized Tissue Following Alveolar Ridge Reduction and Implant Placement for Mandibular Prosthesis, Journal of Oral and Maxillofacial Surgery (2014), doi: 10.1016/ j.joms.2014.07.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Use of Transalveolar Sutures to Maintain Vestibular Depth and Keratinized Tissue Following Alveolar Ridge Reduction and Implant Placement for Mandibular Prosthesis
RI PT
George R. Deeb, DDS, MDa, Janina Golob Deeb, DDS, MSb, Daniel M. Laskin, DDS, MSc and Vickas Agarwal, BSd
a
SC
Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, 521 North 11th Street, Richmond 23298 b
M AN U
Assistant Professor, Department of General Practice, School of Dentistry, Virginia Commonwealth University, 521 North 11th Street, Richmond 23298
c
Professor Emeritus, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, 521 North 11th Street, Richmond 23298 Student, School of Dentistry, Virginia Commonwealth University, 521 North 11th Street, Richmond 23298
AC C
EP
TE D
d
ACCEPTED MANUSCRIPT
Use of Transalveolar Sutures to Maintain Vestibular Depth and Keratinized Tissue Following Alveolar Ridge Reduction for Implant Placement for Mandibular Implant Prosthesis
RI PT
George R. Deeb DDS, MD, Janina Golob Deeb DDS, MS, Daniel M. Laskin DDS, MS and Vickas Agarwal BS
M AN U
SC
Reconstruction of the totally edentulous patient with dental implants has become a routine treatment with predictable outcomes. Firm keratinized tissue surrounding the implants and adequate vestibular depth are among the determining factors for long-term implant success. In the staged approach of mandibular implant reconstruction, adequate vestibular depth as well as attached gingiva surrounding the implants can be readily established at the time of implant placement or when the implants are uncovered. However, in cases when extractions and necessary mandibular ridge reduction to create adequate width are done immediately prior to implant placement, maintaining adequate keratinized tissue around the implants, as well as preventing prolapse of the vestibule, can present a challenging situation. The aim of this report is to present a technique that allows the surgeon to stabilize the vestibular depth and at the same time position the flaps around the implants to preserve the attached gingiva.
TE D
Technique
AC C
EP
A mid-crestal incision is performed in edentulous areas and a sulcular incision is used to release the gingiva around the remaining teeth. Full thickness mucoperiosteal flaps are released on facial and lingual aspects extending bilaterally between the first molar sites or to the distal of extracted teeth. The extractions are done as atraumatically as possible, followed by bicortical mandibular alveolar reduction to the predetermined level and routine implant placement (Figure 1). The amount of bone reduction necessary for prosthetic height, as well as mandibular width to contain the implants, is determined on the preoperative cone beam CT by measuring from the incisal edge of the remaining teeth. After implant placement, a straight fissure bur is used to make transalveolar channels in the alveolar bone between implants starting on the outer facial surface and through lingual aspect of the mandible. Alternatively, only perforation of the lingual cortical bone may be used in cases where vestibular depth is not as critical as positioning the tissue drape apically and controlling the zone of keratinized tissue (Figure 2). The osteotomies are positioned up to 5 mms apical to the height of the alveolar ridge or just apical to it, depending on the amount of vestibular depth required (Figure 5). The number of osteotomies for transalveolar fixation sutures depends on the number of implants placed and the distance between them.
ACCEPTED MANUSCRIPT
RI PT
Once the osteotomies for channels have been completed, a 3.0 polyglactic suture on a minimally curved needle is introduced through the facial flap before entering into the transalveolar channel and then engaging the lingual flap upon exiting (Figure 3). The excess mucosa is not excised. After all of the sutures have been placed, a triple knot is tied to closely adapt the flaps to the underlying bone and to secure the keratinized tissue around the implants on both the lingual and facial aspects (Figure 4). Wound closure is completed by suturing the mucosal margins with interrupted sutures (Figure 6). In case of tissue irritation, transalveolar sutures can be removed at post-operative visit once stable tissue adaptation to underlying bone is achieved (Figure 7). Discussion
M AN U
SC
Bone anchoring sutures have been described previously for adapting soft tissue around single stage dental implants1. This technique improves seating and healing of the gingival tissues, secures vestibular depth, and reduces subsequent mobility of the facial and lingual flaps in a coronal direction following mandibular implant placement1. Traditionally, unsecured flaps migrate coronally and vestibular depth and the amount of keratinized tissue surrounding the implants are compromised. For restorative purposes and plaque removal, this presents a challenge. We present several modifications to previously described technique and expand the application to immediate implant placement in conjunction with extractions, alveloplasty and alveolectomy as well as immediate implant placement and loading.
AC C
EP
TE D
With this technique, sutures are placed bisecting the inter-implant alveolar bone, thus avoiding the immediate peri-implant tissues. Ideally, there should be a transalveolar suture between each implant site, and include transalveolar sutures distally to the most distal implant site. When implant retained, tissue supported restorations, such as the two implant overdenture, are planned, suture osteotomies are placed apically up to five mm to increase vestibular depth to allow for flange extensions. When planning for completely implant supported prosthesis, such as hybrid restorations, perforation of only one cortex at the crest is utilized in order to decrease tissue prolapse and control the position of the attached gingiva. Further work to identify the ideal vestibular depth in both types of restorations is being carried out at this time and will be analyzed statistically in an IRB sanctioned study. The authors are also applying a variation of the technique to maxillary surgery and will share their results when an adequate number of cases are completed. Single stage surgery in conjunction with extractions when indicated is our preferred treatment. The reduced number of surgical procedures has many benefits for the patient. These include reduced anesthetic risks, postoperative pain and complications, as well as decreased length of overall treatment time. The success rate of the implants placed in a single stage surgery compared to the those placed with delayed uncovering has been shown to be favorable.3 Often patients experience significant atrophy of the keratinized tissue of the edentulous mandible, as well as frequent perforations over the cover screws during the healing period of buried implants.4-5 These conditions present the surgeon at the uncovering of the implants with a challenge on how to recreate the prosthetic space on both the lingual
ACCEPTED MANUSCRIPT
and buccal aspects of the implants, as well as how to restore keratinized tissue to the peri-implant regions.
RI PT
The presence of attached gingiva measuring 2 mms or less at the site of insertion has been associated with a high rate of early implant failure.6 Thin or absent gingival tissue around implants has been associated with bleeding on probing and greater loss of alveolar bone supporting the implants.8 On the other hand, having an adequate zone of gingiva around implants facilitates plaque control and the interface with prosthetic devices, and has been associated with improved long-term success and stability of implants.7
M AN U
SC
With the goal of creating a thicker band of attached gingiva around implants, a second surgical procedure is often performed before the restorative treatment phase. Free gingival grafting procedures and vestibuloplasties have been shown to produce significant postoperative discomfort and bleeding in patients.9 There is also the added challenge to increase the width of gingiva as well as the prosthetic space on the lingual aspect of implants in edentulous mandible.10 Securing both the lingual and buccal flaps apically to a fixed and stable bony anchorage greatly reduces the likelihood of prolapse of the buccal vestibule and elevation of the lingual floor into prosthetic space as well as beyond the implant margins. This fixed anchorage is especially important in patients that cannot wear prosthetic devices during the healing phase.11
TE D
Studies have confirmed that attaching healing abutments at the time of implant placement does not adversely influence the outcome of implant treatment either in regard to marginal bone loss or the health of the soft tissues around the implant.12 Single stage surgery with the placement of healing abutments actually allows the patient the additional benefit of greater prosthesis retention during the healing stage.13
AC C
EP
Evaluation of this technique so far shows that it is successful in preventing tissue overgrowth above and onto the surface of the implant following healing (Figure 7). Further, patients do not have any additional discomfort other than that associated with the implant placement itself. It is also important to note that the osteotomies made to secure the sutures were reossified within 6 months (illustrated radiographically).1,2
Conclusion
Increased postoperative complications and the prolonged treatment time associated with staged implant therapy have led to a search for improvement in stabilizing keratinized tissue and vestibular depth at the time of implant placement in the edentulous mandible, hence eliminating the need for a second surgery. The use of transalveolar sutures successfully fulfills these goals.
SC
RI PT
ACCEPTED MANUSCRIPT
References:
AC C
EP
TE D
M AN U
1. Altiparmak N, Uckan S: Bone anchoring of sutures for adequate repositioning of the soft tissue flaps in one stage dental implants. Int J Oral and Maxilllofac Surg 42:535, 2013 2. Lauer G, Schwarz U, Schilli W: Transalveolar fixation of the peri-implant soft tissue in the mandible: surgical method and clinical follow-up. J Oral and Maxillofac Surg 54:690, 1996 3. Shigerhara S, Ohba S, Nakashima K, Takanashi Y, Asahina I: Immediate loading of dental implants inserted in edentulous maxillas and mandibles; 5-year results of a clinical study. J Oral Implantol 2014. 4. Weber HP, Cochran DL: The soft tissue response to osseointegrated dental implants. J Prosthet Den 79:79, 1998 5. Cehreli MC, Kökat AM, Uysal S, Akca K: Spontaneous early exposure and marginal bone loss around conventionally and early-placed submerged implants: a double-blind study. Clin Oral Implants Res 21:1327, 2010 6. Baqain ZJ, Moqbel WY, Sawair FA: Early dental implant failure: risk factors. Br J Oral Maxillofac Surg 50:239, 2012 7. Block MS, Kent JN: Factors associated with soft- and hard-tissue compromise of endosseous implants. J Oral Maxillofac Surg 48:1153, 1990 8. Bouri A, Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I: Width of keratinized gingiva and the health status of the supporting tissues around dental implants. Int J Oral Maxillofac Implants 23:323, 2008 9. Griffin TJ, Cheung WS, Athanasios IZ, Damoulis PD: Postoperative complications following gingival augmentation procedures. J Periodontology 77:2070, 2006 10. Stimmelmayr M, Stangl M, Edelhoff D, Beuer F: Clinical prospective study of a modified technique to extend the keratinized gingiva around implants in combination with ridge augmentation: oneyear results. Int J Oral Maxillofac Implants 26:1094, 2011 11. Peñarrocha M, Boronat A, Garcia B: Immediate loading of immediate mandibular implants with a full-arch fixed prosthesis: a preliminary study. J Oral Maxillofac Surg 67:1286, 2009. 12. Watson CJ, Ogden AR, Tinsley D, Russell JL, Davison EM. A 3- to 6-year study of overdentures supported by hydroxyapatite-coated endosseous dental implants. Int J Prosthodontics 11:610, 1998
ACCEPTED MANUSCRIPT
SC
RI PT
13. Liddelow GJ, Henry PJ: A prospective study immediately loaded single implant mandibular overdentures: preliminary one-year results. J Prosthet Dent 97:126, 2007 14. Karandikar S, Bhawsar S, Varsha Murthy J, Pawar P, Yuvaraj V, Dalsingh V: Bhawsar-karandikar stent: an aid to vestibuloplasty. J Maxillofac Oral Surg 12:237, 2013
Figure Legends
M AN U
Figure 1: Five lower implants placed for an immediate loaded full arch provisional restoration. Figure 2: Close up photo of a fissure bur being used to make an inter-implant osteotomy of the lingual cortical bone as means for stabilizing flaps in an apical position. In this example the lingual cortex is being perforated due to wide bucco-lingual dimension of the alveolar ridge, as well as to avoid inadvertent damage to the implants.
TE D
Figure 3: Intraoperative photograph showing the suturing sequence. The operator will pass from the buccal tissues through the alveolus and the through the lingual tissues before tying the knot over the ridge to secure the tissues.
EP
Figure 4: Intraoperative photograph with three transalveolar sutures in place. The sutures are placed in the inter implant bone and secured. The rest of the final closure is completed in chromic gut suture. Note the preservation of keratinized tissue and apical position of the flaps.
AC C
Figure 5: Intraoperative photograph post implantation showing the needle being passed through the alveolus in order to demonstrate the placement of the transalveolar osteotomy in a 5 mm apical position. For altering vestibular height the osteotomy should be placed apically as shown. For utilization the buccal flap should be engaged before entering the osteotomy and the lingual flap upon exiting as in figure 3. Figure 6: Immediate postoperative view of the closure utilizing the transalveolar suture (arrow) securing the flaps in an apical position in order to increase vestibular depth. Figure 7: One week postoperative photo showing favorable healing and stable tissue adaptation around the implants. The transalveolar sutures (arrows) are still intact.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 1: Five lower implants placed for an immediate loaded full arch provisional restoration.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 2: Close up photo of a fissure bur being used to make an inter implant osteotomy of the ligual cortical bone as means for stabilizing flaps in an apical position. In this example the ligual cortex is being perforated due to wide bucco-lingual dimension of the alveolar ridge as well as to avoid inadvertent damage to the implants.
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Figure 3: Intraoperative photograph showing the suturing sequence. The operator will pass from the buccal tissues through the alveolus and the through the lingual tissues before tying the knot over the ridge to secure the tissues.
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
Figure 4: intraoperative photograph with three transalveolar sutures in place. The sutures are placed in the inter implant bone and secured. The rest of the final closure is completed in chromic gut suture. Note the preservation of keratinized tissue and apical position of the flaps.
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
Figure 5: Intraoperative photograph post implantation showing the needle being passed through the alveolus in order to demonstrate the placement of the transalveolar osteotomy in a 5 mm apical position. For altering vestibular height the osteotomy should be placed apically as shown. For utilization the buccal flap should be engaged before entering the osteotomy and the lingual flap upon exiting as in figure 3.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 6: Immediate postoperative view of the closure utilizing the transalveolar suture (arrow) securing the flaps in an apical position in order to increase vestibular depth.
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
Figure 7: One week postoperative photo showing favorable healing and stable tissue adaptation around the implants. The transalveolar sutures (arrows) are still intact.
