Tissue-Punch Technique in Nonattached Tissue Using the YSGG Laser

Osseointegration has become a highly predictable dental procedure. Dental implants placed by raising a surgical mucoperiosteal flap can cause a number of complications including tissue recession, crestal bone loss, and scarring. Postoperative pain and swelling are also associated with this technique.1 It has been shown that surgical trauma includes thermal injury and mechanical trauma which can cause microfracturing of the bone during implant placement.2
The purpose of this article is to present the use of a flapless technique for placing dental implants in areas where inadequate attached (keratinized) tissue is present. In the case report which follows, computerized tomography (CT) scan technology is utilized to achieve exact implant placement along with the use of the Er;Cr:YSGG laser (Biolase Technology) to tissue weld keratinized tissue to zones of nonkeratinized tissue.

BACKGROUND ON FLAPLESS IMPLANT SURGERY

When teeth are present, blood supply to the bone comes from 3 different paths: the periodontal ligament, connective tissue above the periosteum, and from inside the bone. When a tooth is lost, blood supply from the periodontal ligament disappears, so blood that now comes only from soft tissue to the bone is removed thus prompting bone resorption during the initial healing phase.3 With a flapless approach, surgical trauma is minimal because the circular incision is very small resulting in much less postoperative pain, swelling, and discomfort.
With appropriate case selection, flapless implant surgery is a predictable procedure when the surgical technique is performed correctly. Correct bur angulation is also critical when doing this procedure. Placing an implant using a flapless technique depends heavily on the quantity and morphology of the bone that will receive the implants as well as the surgical expertise of the clinician. A 10-year clinical retrospective analysis done by Campelo et al3 states that the success rate approached 100% after the clinician gained over 5 years of experience in doing this procedure.3

 

CT SCAN TECHNOLOGY

The use of CT scan technology used for diagnosing and treatment planning dental implants has allowed for a more accurate understanding of the tooth-to-bone anatomical relationship. Such reconstructions and models can be created from CT scans with the use of the Simplant Planner (Materialise). This program helps the dentist to accurately measure distances, angles, and bone density resulting in precise implant placement.4
Being able to observe the underlying bone with CT scans allows one to do flapless implant placement. Thus, it reduces the associated surgical morbidity, minimizes bleeding, reduces the amount of postoperative pain and swelling, improves aesthetics, and the gingival attachment around the abutment is rapidly and completely achieved.2 But what happens if there is not enough attached tissue that surrounds the facial (buccal) aspect of the implant placement? Why is this procedure not routinely preformed? Some clinicians have stated on the OsseoNews discussion line that, “This surgery (flapless implant surgery) is motivated by the selling of dental implants.” Dr. Myron Nevins (past recipient of the American Academy of Periodontology Master Clinician Award) stated that he has “done surgery all day for his entire professional career” and that he “does not have a comfort level with this type of procedure.”

YSGG LASER: THE BENEFITS

The YSGG laser has assisted in speedy healing, decreasing postoperative pain, and increasing bone to implant contact.5,6 Lasers have been FDA-approved for cutting enamel, dentin, and soft tissue. For implant dentistry, laser can be used in cutting flap preparations, detoxifying the osteotomy site, starting regional acceleratory phenomenon (RAP), tissue welding, accelerating angiogenesis7-10, and in promoting biomodulation to help repair damaged cells while reducing pain.11-13 An easy application of the YSGG laser is the ability to bring the soft-tissue edges together using heat. This is referred to as “tissue welding.” The welding together of tissue is accomplished with a uniform heating of 70 to 80 C0, where there is adherence between the layers. The layers stick together because of the collagen molecule’s helical unfolding and intertwining with adjacent segments.14

CASE REPORT

A 52-year-old female presented to the office for an evaluation regarding the replacement of a missing tooth No. 30 with a dental implant. The tooth was lost due to a fractured root following root canal therapy (RCT). She had had RCT therapy 15 years prior, and then the tooth became symptomatic 4 years ago at which time it was surgically extracted. The patient’s main complaint was unhappiness with having a missing tooth. Patient was in good physical condition. Additionally, there were no significant medical problems noted on the patient’s health history. The patient’s dental history presented with numerous alloy restorations in the posterior teeth and crowns on teeth Nos. 3, 15, and 19, with RCT in tooth No. 15. Besides missing tooth No. 30, the patient was missing teeth Nos. 1, 16, 17, and 32. There was no soreness in the muscles of mastication, nor any history of temporomandibular disorder problems.
Dental records were obtained including a periapical x-ray of tooth No. 30, a panorex film, upper and lower alginate impressions for SurgiGuide (Materialise) creation, a face-bow (Panadent) taken, and an anatomical wax-up of tooth No. 30.


Figure 1. Preoperative photo.

CT SCAN: THE PLANNING PHASE

A CT scan was completed at the time the patient presented to our office and this was reformatted for use with the SimPlant Planner software. From the SimPlant program, the ideal position to place an implant was chosen. Hounsfield values were in the range of 800. In the first molar region, the average person exerts a force between 150 to 250 psi.15 Patients who grind or clinch their teeth exert forces that can approach 1,000 psi. Due to the position in the mouth, it was decided that this would be a 2-stage implant. The SimPlant planner showed that the width of the ridge was 9.96 mm at the crest, 11.52 mm at the midcrest, and the length to the inferior alveolar canal was 12.82 mm. There was no lingual concavity. The length between teeth Nos. 31 and 29 was 12.82 mm. A 5.0 x 13.00 mm
A Select Groovy implant (Nobel-Biocare) was selected to fit into the desired space. (As part of the Sim-Plant planner, the clinician can e-mail for the fabrication of the Surgi-Guide.) In this case the diameter of the guides were 2.0, 3.5, and 4.3. After being informed about the pros and cons of every option, the patient opted for an implant-supported crown.
From the markings on the study model, it was determined that the buccal aspect of the osteotomy would be in nonkeratinized tissue (Figure 1). The presence of keratinized tissue next to an oral implant presents greater benefits than with natural teeth. Some reports indicate the lack of keratinized tissue may contribute to implant failure. Kirsch and Ackermann reported that the most important criterion for implant health, in the posterior mandible, was related to the presence or absence of keratinized tissue,16 thus it was decided that a keratinized tissue graft would be accomplished at the time of implant placement.


Figure 2. Tissue punch into SurgiGuide.

Figure 3. Keratinized and nonkeratinized tissue saved from the tissue punch.

Figure 4. Internally irrigated drill used with SurgiGuide.

THE SURGICAL PHASE BEGINS

The patient rinsed with Peridex (3M ESPE/Omni) orally for 30 seconds. Next, venapuncture was accomplished in the right antecubital fossa and IV sedation was performed to produce a mildly sleepy state. The drugs used were Versed, Nubain, and Benadryl. On completion of the sedation, dexamethasone and cefazolan were used. Local anesthetics (20 mg of Lidocaine with 10 mcg of epinephrine and 5 mg of Marcaine with 5 mcg of epinephrine) were administered as well.
The SurgiGuide with a 4.3-mm-diameter ring was seated, and rotary tissue punch was used to remove the tissue to appropriate position as designed by the SimPlant planner (Figure 2). The tissue was removed with the aid of a periosteal elevator and set aside on a (moistened) sterile gauze for later use (Figure 3). The SurgiGuide with a 2.0-mm-diameter ring was seated and a pilot drill was used with external irrigation, drilling to the desired length. This was followed by the 3.5-mm-diameter ring and an internally-irrigated drill was used. This was followed by the 4.3-mm-diameter ring (Figure 4) and the 5.0-mm-diameter ring, using the drill in the same fashion.


Figure 5. YSGG laser used to detoxify and start the regional acceleratory phenomenon.

Figure 6. Seating implant.

Figure 7. Impression post seated on implant.

Figure 8. A PVS impression (Aquasil [DENTSPLY CAULK]) is taken day of surgery.

Figure 9. Keratinized tissue is trimmed and measured for placement.

Figure 10. YSGG laser is used to create a split-thickness pouch.

Figure 11. Tissue is seated into pouch.

Figure 12. YSGG laser used to tissue weld the nonkeratinized to keratinized layers.

Figure 13. Periacryl (GluStitch) cement is placed on the tissues.

USING THE YSGG LASER

After the osteotomy was prepared, a periodontal probe was used to feel the walls of the preparation to determine that all were in bone. Feeling all bony tissue, the YSGG laser was then used (Figure 5) as reported by Kusek.6 Periotest values increased 40% when lased areas were compared to nonlased areas. These results were achieved by a single use with a setting of 0.5 W 20 Hz 7/14; used in such a way that the laser tip was initiated at the apex of the osteotomy site and then moved up coronally in a counterclockwise pattern. Using this technique appears to start the RAP to increase the amount of fibroblasts forming in these areas, thus resulting in the increased Periotest values. This procedure not only detoxifies the site, but also increases the fibroblast attachment to the implant. The author is suggesting that a D-4 bone can be changed to D-3, or even D-3 to D-2. This allows more biomechanical stress to placed in the bone, which ultimately increases success rates.17
The implant was seated flush (Figure 6) to the crest of the ridge. An impression post was seated (Figure 7) and an x-ray was taken to insure that the post was seated flush to the implant body. A custom tray was utilized and filled with a polyvinyl siloxane (PVS) (Aquasil Ultra [DENTSPLY CAULK]) impression material. Next, the impression post was removed and placed into the impression (Figure 8) for the lab to fabricate custom post and crown. A PVS impression material (BluMousse [Parkell]) was then used to take a bite registration.
The tissue used from the tissue punch was then used. First, it was measured for the appropriate length (Figure 9) and thinned. The area buccal to the implant was prepared using a split-thickness reflection with the YSGG laser (Figure 10). A setting of 1.25 W. 30 Hz 9/14 was used in the hard tissue mode. A pocket was made with the Z-6 tip allowing the periosteum to cover the bone, but loosening the tissue to an area of 6 mm depth. The tissue that had been trimmed was placed into the pocket, buccal to the implant (Figure 11). Laser energy was painted over the keratinized and nonkeratinized tissue, welding them together (Figure 12) giving the tissue a white blanched look. Finally, PeriAcryl (GluStitch) cement (Figure 13) is applied to the tissues. Photomodulation (LaserSmile [Biolase Technology]) was done under the pulsed mode at 1.5 W. 30/30 for 30 seconds. Using photomodulation allows the cells to repair themselves quickly and reduces any histamine release. Photomodulation energizes the mito-chondria within the cells to produce this effect.11-13 After the patient was taken off sedation, a new face-bow (Panadent) registration was taken.


Figure 14. 5 days post-op. Figure 15. 3 months post-op.

Figure 16. The completed case with the restoration cemented.

Figure 17. Another dramatic result in a different case using this flapless implant surgical technique.

DISCUSSION

The patient rated the pain index for this surgery at 0 on a scale from 0 to 10 (with 10 being the most severe pain ever experienced). In fact, the patient later stated that she only took her initial pain analgesic and did not need any other pain medication postoperatively. Note the 5-day postoperative photo (Figure 14). The tissue integration at that time was highly organized. The case was seated after a 3-month healing period. Note the band of keratinized tissue present at the buccal aspect of the final post (Figure 15). In fact, in the uncovering/seating appointment all that was needed was to unscrew the healing cap, screw in the custom post fabricated by the lab, verify the fit to the implant with x-ray, seat the final crown, check the occlusion/contacts, and cement the crown (Figure 16). The Periotest value for this case was a -6, which was over 40% higher than nonlased cases.
Figure 17 shows another dramatic result in a different case using this technique, and how the tissue was already organizing into keratinized tissue after just 4 days. This allowed for doing the case using the tissue punch technique, when it would have otherwise been contraindicated due to lack of keratinized tissue. Keratinized tissue was placed at the surgical appointment and we were able to finish this case in 3 months with very little chair time.
Flapless implant surgery is here to stay. The 3 problems associated with flapless implant surgery are easily handled:

  • Regarding osseous defects that cannot easily be detected: With CT technology, and the use of SurgiGuide for exact implant placement for the patient’s morphology, the procedure has been made more predictable since the clinician knows before surgery what will be encountered.
  • Regarding placement in areas of nonkeratinized tissue: This has easily been accomplished in matter of few minutes with the use of laser-tissue welding using the YSGG laser done under low level radiation. This technique can be done with minimal surgical skills.
  • Regarding a surgery that is technique sensitive and normally takes a good number of cases to master: Performing the technique as described in this article allows even a novice to comfortably do this implant surgery.

CONCLUSION

Technology is changing dentistry for the better! It enhances the level of patient care, increases our communication abilities, and it makes the clinician more efficient. The standard of care is being raised by these new technologies. We as clinicians can embrace new concepts, or hide and watch dentistry change before our eyes. That is not to say we cannot learn from our mistakes; shortcuts cannot be taken (ie, not using CT scan and 3-D reformatting). However, when done properly as described in this article, flapless implant surgery is a viable option for dental implants.
Laser technology is yet another adjunct that aids in the success of the entire case and it is on the verge of changing implant dentistry forever. It is a win for the patient (less pain, swelling, and quicker healing time) and a win for the dentist (faster healing time, better aesthetics, and less chair time).


References

  1. Oh TJ, Shotwell J, Billy E, et al. Flapless implant surgery in the esthetic region: advantages and precautions. Int J Periodontics Restorative Dent. 2007;27:27-33.
  2. El Attar MS, Mourad HH, Mahmoud A, et al. Early osteotomy with delayed implant placement: a step further for immediate loading. Implant Dent. 2006;15:18-23.
  3. Campelo LD, Camara JR. Flapless implant surgery: a 10-year clinical retrospective analysis. Int J Oral Maxillofac Implants. 2002;17:271-276.
  4. Ganz SD. The reality of anatomy and the triangle of bone. Inside Dentistry. 2006;6:72-77.
    http://www.drganz.com/insidedentistryfinal.pdf. Accessed February 12, 2007.
  5. Rizoiu IM, Eversole LR, Kimmel AI. Effects of an erbium, chromium: yttrium, scandium, gallium, garnet laser on mucocutaneous soft tissues. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;82:386-395.
  6. Kusek ER. Use of the YSGG laser in dental implant surgery: scientific rationale and case reports. Dent Today. Oct 2006;25:98-103.
  7. Frost HM. The biology of fracture healing. An overview for clinicians. Part I. Clin Orthop Relat Res. Nov 1989:283-293.
  8. Frost HM. The biology of fracture healing. An overview for clinicians. Part II. Clin Orthop Relat Res. Nov 1989:294-309.
  9. Shih MS, Norrdin RW. Regional acceleration of remodeling during healing of bone defects in beagles of various ages. Bone. 1985;6:377-379.
  10. Pinheiro AL, Pozza DH, Oliveira MG, et al. Polarized light (400-2000 nm) and non-ablative laser (685 nm): a description of the wound healing process using immunohistochemical analysis. Photomed Laser Surg. 2005;23:485-492.
  11. Trelles MA, Mayayo E. Bone fracture consolidates faster with low-power laser. Lasers Surg Med. 1987;7:36-45.
  12. Takeda Y. Irradiation effect of low-energy laser on alveolar bone after tooth extraction. Experimental study in rats. Int J Oral Maxillofac Surg. 1988;17:388-391.
  13. Dörtbudak O, Haas R, Mallath-Pokorny G. Biostimulation of bone marrow cells with a diode soft laser. Clin Oral Implant Res. 2000;11:540-545.
  14. Pick RM, Powell GL. Laser in dentistry. Soft-tissue procedures. Dent Clin North Am. 1993;37:281-296.
  15. Cochran DL, Hermann JS, Schenk RK, et al. Biologic width around titanium implants. A histometric analysis of the implanto-gingival junction around unloaded and loaded nonsubmerged implants in the canine mandible. J Periodontol. 1997;68:186-198.
  16. Kirsch A, Ackermann KL. The IMZ osteointegrated implant system. Dent Clin North Am. 1989;33:733-791.

Dr. Kusek is a 1984 graduate of the University of Nebraska School of Dentistry. He has been a general dentist for more than 24 years in Sioux Falls, SD. He is a Diplomate of the American Board of Oral Implantology/Implant Dentistry and the International Congress of Oral Implantologists, a Fellow of the American Academy of Implant Dentistry, and has earned Mastership in the World Clinical Laser In-stitute and the Academy of General Dentistry. He is adjunct professor at the University of South Dakota and lectures internationally on YSGG lasers. He can be reached at (605) 371-3443 or implantdental@midconetwork.com.

Disclosure: Dr. Kusek lectures for but has no financial interest in Biolase or funding from the manufacturer for research studies.



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