Grafting for Implant Dentistry

Michael Tischler, DDS

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It has been said, ‘The bone sets the tone, and the tissue is the issue.’ The underlying available, or grafted, bone is the foundation for the soft tissue. Through contouring underlying bone, and grafting deficient areas needed for implant or aesthetic support, adequate soft tissue can be supported.

This month, I would like to briefly discuss soft- and hard-tissue grafting for implant dentistry. The success of one or more dental implants is dependent on both the soft tissue and hard tissue surrounding the implant. While many other factors come into play, soft and hard tissues have an immediate physical contact with all implant components, creating immense importance for success.

The soft tissue that surrounds a dental implant has a cosmetic, structural, and protective role. The soft tissue around the coronal area of an implant is a main guardian against pathogenic bacteria that could invade the peri-implant space. Through surgical manipulation to place keratinized tissue around the coronal area of dental implants, this thicker gingival biotype allows for a protective barrier. The positioning of keratinized tissue is first planned for during the initial incision before implant placement. Through bringing the existing band of keratinized tissue towards the facial aspect of an implant via the suturing step, an increased barrier is created. If there is inadequate keratinized tissue naturally available at the time of implant placement, then either an autogenous or a donor soft-tissue graft should be placed. A second opportunity to graft is at uncovery during a 2-stage procedure. When a one-stage procedure is performed without uncovery, grafting should be done at implant placement. Ideally, it is best to have as much attached keratinized gingiva as possible since the attachment to the underlying periosteum creates a superior barrier.

Soft tissue around an implant plays an aesthetic role, especially in the maxillary anterior region. The tone of the tissue, as well as its thickness and height, are important aesthetic factors. The thickness and quality of the gingival biotype can be a crucial element for aesthetic success. With thin mucosa, the dark color of titanium implants often shows through, unless keratinized gingiva is present and ample enough to mask the underlying shade.

It has been said that “The bone sets the tone, and the tissue is the issue.” The underlying available, or grafted, bone is the foundation for the soft tissue. Through contouring underlying bone, and grafting deficient areas needed for implant or aesthetic support, adequate soft tissue can be supported. In my practice, I have been a proponent of demineralized freeze-dried bone allograft (DFDBA) putty for many years. I like these putties because they are hemostatic, stay in place, resist pressure from a removable prosthesis, and are osteoinductive. It should be noted that particulate DFDBA materials tend to migrate, unless mixed with PRF.
In this issue, our Implants Today Advisory Board member Dr. Timothy Kosinski expertly answers some questions pertaining to tooth extractions and grafting. I hope that you will find his insights and perspectives on site development very helpful.

If you have any questions or comments about this topic, or any other subject presented in Implants Today, feel free to contact Dr. Tischler at mt@tischlerdental.com.

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