Periodontal, Functional, and Esthetic Integration of Peri-Implant Soft Tissue: WHS Concept
The long-term functional success of implant treatment depends on the stability of the crestal bone around the implant platform. The esthetic result is achieved by adequate quality and quantity of soft tissue in the peri-implant area. The soft tissue creates the buffer area that ensures the mechanical and biological protection of the underlying bone. Therefore, it is necessary to maintain in the long term, not only implant osseointegration, but also the integrity of the soft tissue around the sub- and suprastructures of the implant restoration. To create the protective soft tissue area, it is necessary to ensure 3 criteria. This treatment approach will be defined as TWS–soft tissue management: T for thickness, W for width, and S for stability. There are many ways to achieve the first 2 criteria, which are described in the literature. Achieving the third criterion of stability has become possible only recently because of the development of digital treatment planning, surgically guided, and prosthetic-assisted technology that uses a 1-time abutment and its implementation into the dental practice. The purpose of this article is to present with clinical cases a detailed description of each criterion.
Figure 1. Gingival thickness before the implantation.
Figure 2. Single incision Connective Tissue Graft harvesting from the palate.
Figure 3. The Connective Tissue Graft attachment to the muco-periosteal flap.
Figure 4. Gingival thickness after the implant placement and augmentation of soft tissue.
Figure 5. After the installation of the healing abutment.
Figure 6. The radiographic demonstration of the absence of the cervical bone resorption.
Figure 7. Permanent restoration fixation.
Figure 8. Clinical photograph and radiograph at 1 year after fixation of the permanent restoration.
Figure 9. Case report video.
Figure 10. Absence of an optimal band of keratinized gingiva.
Figure 11. Creation of an optimal band of attached keratinized gingiva with a FECTG.
Figure 12. Attached keratinized gingiva with enough width.
Figure 13. Permanent restoration placed.
Figure 14. The obtained height of the attached gingiva was >5 mm, and evidence of mechanical trauma was absent.
Figure 15. The radiographic examination demonstrates the absence of the bone resorption adjacent to the implant platform.
Figure 16. The indications for extraction of teeth #8 and #9 were established.
Figure 17. The crack in the root of tooth #9.
Figure 18. Perforation in middle third of the root for tooth #8.
Figure 19. Patient's virtual model created to demonstrate bone level and soft tissue contours to assist in providing ideal 3D positioning of implants.
Figure 20. During the surgery, teeth #8 and #9 were extracted using a minimally invasive technique.
Figure 21. Preparation of the plate for the implants was provided using special cutters with a thickness in the tail area that ensures proper positioning in the matrix part of the guide.
Figure 22. Combining of the special location elements of the surgical guide and implant driver.
Figure 23. The implants image installed in the perfect 3D position with orientation of their antirotation elements.
Figure 24. The prefabricated permanent individual abutments and temporary crowns.
Figure 25. The 1-time abutments were fixed to the implants with screws using torque of 35 n/cm.
Figure 26. Radiograph after installation of the implants and permanent individual abutments.
Figure 27. Temporary crowns were fixed to the abutments with permanent cement.
Figure 28. View of the individual abutments before preparation of the temporary crowns.
Figure 29. Cone Beam Computed Tomography with the 1-time abutments.
Figure 30. Lateral view of the permanent (definitive) prothesis.
Figure 31. Frontal view of the permanent prosthesis.
Figure 32. Video of the digital protocol of navigation implantation (DDS). Surgical stage.
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