Peri-implant yumuşak doku komplikasyonunun tedavisinde bir modifiye serbest diş eti grefti yaklaşımı

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Introduction
Mucosal irritation, gingival hyperplasia, periimplantitis, inadequate vestibular depth and insufficient attached tissue are most of the reported
problems associated with the soft tissue around dental implants (1-3). Although the lack of keratinized
tissue may not influence implant survival, careful
management of soft tissue around implants is considered essential by clinicians to prevent the potential
problems indicated above (4). The increasing esthetic demand in implant dentistry and the subsequent
need to treat and/or prevent soft tissue problems occurring around dental implants have favoured the
development of many surgical techniques including
vestibuloplasty, use of freeze-dried skin, split or full
thickness skin grafts and free gingival grafts (2,3,5).
Since it was described by Bjorn in 1963 (6), the free
gingival graft technique was widely utilized for the
treatment of mucogingival problems in periodontal
surgery and its predictability was marked, which demonstrated the stability of newly keratinized tissue
up to several years (7).
The use of fibula osteoseptocutaneous flaps (fibulafree flaps) in the presence of bone and soft tissue continuity defects has become a valuable means for the
rehabilitation of these patients. Further, the possibility of placing dental implants in the reconstructed
areas permits to overcome the problems related to
the dental rehabilitation with removable prostheses
(8). However, scar (or scar-like tissue) formation is
usually an inevitable complication that occurs following a fibula-free flap surgery and may cause several
problems such as tissue resistance to blade or other
surgical instruments, interruption of the vascularization during or following subsequent intraoral operations. Unfortunately, present mucogingival surgical
techniques do not indicate any solutions in order to
eliminate this problem.
* Department of Periodontology, Center of Dental Sciences, Gulhane
Military Medical Academy, Ankara, Turkey
** Private Practice in Periodontology, Ankara, Turkey
*** Department of Oral and Maxillofacial Surgery, Center of Dental Sciences,
Gulhane Military Medical Academy, Ankara, Turkey
**** Turkish Military Academy, Dental Service, Ankara, Turkey
This case report was presented in European Association for Osseointegration
17th Annual Scientific Meeting Warschaw, September 2008
Reprint request: Sermet Şahin, Department of Periodontology, Center of
Dental Sciences, Gulhane Military Medical Academy, Etlik-06018, Ankara,
Turkey
E-mail: sermetsahin@superonline.com
Date submitted: August 12, 2009 • Date accepted: January 15, 2010128 • June 2010 • Gulhane Med J Şahin et al.
The aim of the present case report is to demonstrate
the use of thick epithelialized free gingival grafting
method for the treatment of a soft tissue complication occurring around dental implants placed into a
fibula-free flap reconstructed mandibular defect.
Case Report
A 23-year-old male patient was referred to the
Department of Periodontology of Gulhane Military
Medical Academy. The history revealed that the anterior mandible was defective and the relevant anterior
teeth had been lost due to a gun shot accident experienced nine months ago. A fibula-free flap surgery had
been performed by the Plastic and Reconstructive
Surgery Department to treat the defective area 2 weeks after this injury. After a 6 months of healing period, 4 dental implants were placed to the grafted area
and 4 weeks after the implant placement, a severe
hyperplasia with a labile tissue around the surrounding mucosa of the implants was noticed.
Intraoral examination of the patient revealed an
exaggerated hyperplastic tissue originating from the
inner mucosa of the lower lip covering 3 of the 4 dental implants (Figure 1). Shallow vestibular sulcus with
insufficient keratinized tissue around dental implants
and a scar-like tissue remaining from fibula-free flap
surgery displaying continuity with the adjacent area
were also present. No peri-implant pathology was
determined.
tissue with #15 scalpels and surgical scissors (HuFriedy Manufacturing, Chicago, IL, USA), a marginal
horizontal linear incision was made along the mucogingival junction at the recipient site. Split-thickness
incision was extended mesiodistally to the mostdistant point where inadequate vestibular depth was
determined and the incision was extended apically
to the deepest point that would provide the desirable band of keratinized mucosa around implants after
completion of the wound healing. A second surgical
site was created on the palate. A thick, rectangular
thick graft in large dimensions (25 mmX9 mmX2.5
mm) was harvested from the donor site at the bicuspid area by a partial thickness incision. The harvested graft was then trimmed according to the borders
of the recipient site and sutured in contact with the
labial mucosa by 4-0 silk sutures (Dogsan, Yalincak,
Trabzon, Turkey) although its mobility was observed
(Figure 2). Mild compress was exerted onto the sutured tissues for 5 minutes with gauze soaked in saline.
A previously fabricated acrylic stent was delivered to
the patient for the protection and stabilization of the
donor site.
Figure 1. Preoperative view of the area revealing an exaggerated
hyperplastic tissue originating from the inner mucosa of the lower lip
and covering three of the four dental implants
Figure 2. Operative view following suturation of the graft. Note that it
was fixed in contact with the labial mucosa (First surgery)
Scaling and polishing were performed to the exposed implant and oral hygiene instructions were given
to the patient at the beginning of the therapeutic procedure. For the epithelialized free gingival graft surgery, a local anesthetic solution (Ultracaine D-S forte,
Hoechst Roussel, Frankfurt, Germany) was administered to both the donor and recipient sites. Following
excision of the exaggerated amount of hyperplastic
A second operation was performed 3 months later
to eliminate the mucogingival problems that still
existed (Figure 3). For this purpose, 2 pieces of free
gingival grafts were obtained from the hard palate
(dimensions: 10 mmX9 mmX2.5 mm and 15 mmX9
mmX2.5 mm) and placed in front of the 2 implants
in the right mandibular area with the same surgical
technique. Tooth brushing activity around the implants was discontinued during this period. The sutures were removed 15 days after both surgeries and
follow-up visits were carried out 1, 3 and 6 months
after the second operation.Volume 52 • Issue 2 Modifi ed graft for peri-implant complication • 129
The postoperative healing was generally uneventful
at the day of the suture removal after both surgeries.
Desirable amount of keratinized tissue was obtained
around all implants except for one at the left side
of the mandible. No marginal tissue movement or
any other mucogingival problems were determined
(Figure 4). Horizontal and vertical dimensions of all
grafts were partially decreased with time. No sign of
mucosal proliferation was observed and the amount
of keratinized tissue was sufficient.
an intra-oral fibula-free flap procedure, there are sparse data about the rehabilitation of a mucogingival
problem around implants following a fibula-free flap.
Some authors suggested several techniques to obtain
adequate amounts of keratinized tissue around implants, mainly based on the preservation of keratinized
tissue. Free gingival graft is utilized in case of an inadequate keratinized tissue or a shallow vestibular depth
around the edentulous ridge and/or dental implants
(3,9). Conventional epithelialized free gingival graft
technique involves placement of the graft in contact
with the attached gingiva and no other modifications
exist in periodontology literature. However, an alternative modality is needed especially in the presence
of a scar-like tissue which may interrupt the utilization of the conventional free gingival technique. In the
present case report, the authors sutured a thick free
gingival graft to the labial mucosa instead of attached
gingiva and obtained sufficient amount of attached
gingiva. Free gingival graft was thought to make function as a physical barrier to prevent the proliferation of
labial mucosa through the implant region.
The healing of the free gingival graft primarily depends on the formation of collateral circulation from
the periosteal and connective tissue bed. A thin blood
clot promotes tensile strength and stability of the wound and healing of a transplanted tissue is dependent
on the development of a new blood supply between
donor tissue and recipient site (10). This stability of
the wound/graft is one of the most critical factors in
achieving a desirable treatment outcome. For this reason, it is considered by the clinicians to place the
graft away from the movable mucosa to protect the
stability of the graft.
Conventional application of epithelialized free gingival graft procedure involves the suturation of the
transplanted tissue to the attached gingiva. In the
present case report, since the floor of the patient’s
mouth was previously rehabilitated with a fibula-free
flap surgery before, it was decided to perform a modification. Although mobility is a major risk factor for
graft mortality, the free gingival graft was sutured proximal to the labial mucosa in this case. Nevertheless,
it was taken care to obtain the thickest tissue as it can
be to reduce the disadvantage about the vascularization. At the end of the healing period, 32-40% of the
graft dimension was lost due to the usual contraction
and this range was compatible with the previous report of Hatipoglu and his co-workers (11).
Acrylic surgical stents were fabricated by some authors for the management of postoperative healing
following intra-oral surgical procedures and satisfactory results were obtained (12). On the contrary,
Figure 3. The graft was again sutured in contact with the labial
mucosa (Second surgery)
Figure 4. Postoperative view following second modified free gingival
graft surgery
It was preferred to wait for 6 months after second free
gingival graft surgery to be sure about the complete
healing without any recurrence. The patient was then
oriented to the Department of Prosthodontics for the
fabrication of permanent implant supported dentures.
Discussion
This clinical report presents the treatment of an
aggressive tissue hyperplasia around mandibular
implants using a modified free gingival graft approach performed to a 23-year-old man. Although many
studies have reported dental implant use following 130 • June 2010 • Gulhane Med J Şahin et al.
the prefabricated stents placed onto the surgical area
following 2 previous vestibuloplasty procedures were
unable to eliminate the recurrence at this patient. As
described in the present report, free gingival technique can be modified by suturing a thick epithelialized
tissue in the presence of an interrupting factor such
as a scar-like tissue in such cases. This technique may
also reduce the necessity of a surgical stent and can be
a fair alternative for protecting the vestibular depth.
Sometimes an undesirable tissue formation such
as scar tissue may interrupt the ideal recipient site
preparation and/or graft placement in free gingival
graft operations. In such cases, literature review does
not demonstrate a suitable alternative to solve this
kind of problems. In conclusion, modified thick epithelialized free gingival graft procedure may be a suitable alternative method for elimination of certain
mucogingival problems around dental implants in
the presence of a scar-like tissue secondary to a previous surgical procedure. In this technique, the graft
was sutured in contact with the labial mucosa where
it was thought to act as a barrier between proliferating labial mucosa and the implantogingival unit.
Although the suggested modified technique does not
seem to be in coherence with the classical graft healing physiology knowledge, clinicians may consider
the reported method in cases they could not obtain
intact and immobile suturing areas