BY DR. JERRY C. HU, DDS
You’ve got an implant patient in your chair, and the first thing you’re thinking, “Do I feel lucky?” Well, do you, implant dentist? Does the patient present with all the required soft tissue health characteristics for successful implant treatment, or don’t they? Considering that the patient's prior periodontal history and willingness to maintain superb oral hygiene habits are the most powerful determinants of success—or could blow your case out of the water—you make a bet and hope your pick lands on the wheel of luck.
In any case, you surrender to the fact that thorough soft tissue risk assessment and evaluation are significant to implant success and must be addressed before spinning the wheel and undertaking any procedures. If patients have or had advanced periodontitis, that—combined with poor hygiene—makes it a sure bet that they are not good candidates for implant treatment. And if patients express a desire to modify their poor oral hygiene habits, the smart wager is waiting some time to allow them to demonstrate a serious commitment, because those habits absolutely correlate to long-term implant success.
Of course, there are other tells—such as smoking and uncontrolled diabetes—that could suggest the deck is stacked against long-term implant success. However, those are actually indicators, as opposed to direct causes, of implant periodontal problems. So to up the odds in you and your patient’s favor, consider what makes for a safer bet (meaning, low risk) and one where the stakes are higher (meaning, high risk).
Low risk implant patients have a healthy medical status, low esthetic expectations, and are non-smokers. They present with a low lip line, low scallop/thick biotype, and rectangular shape. The treatment site has no history of prior infection, intact soft tissue anatomy, and no deficient bone. The bone level of adjacent teeth is less than 5 mm to contact; adjacent restorative status is virgin; and the width of span is ≥ 7 mm.
Note that a thick tissue phenotype is found in more than two-thirds of patients. They are predominantly men with quadratic tooth anatomy, a broad zone of keratinized gingiva, and flat gingival contours.
High risk implant patients, on the other hand, have a reduced immune competence, high esthetic expectations, and are heavy smokers (i.e., more than 10 per day). They present with a high lip line, high scalloped/thin biotype, and triangular shape. The treatment site has acute infection, soft tissue defects, and vertical bone deficiency. Additionally, adjacent teeth are restored, with a bone level of 7 mm to contact, and the width of span is 2 or more teeth.
Here, bear in mind that less than one-third of patients—predominately women with slender tooth anatomy and a narrow zone of keratinized tissue with high scalloping—present with a thin phenotype. Also, an estimated 11% of bicuspids, 24% of cuspids, 23% of lateral incisors, and 7% of central incisors are surrounded by thin phenotype tissue. Remember too, that patients can have a thin phenotype but still have substantial bone (i.e., quantity and quality) underneath.
Not assessing periodontal tissues and a patient’s risk factors is essentially testing their luck and your chances for achieving predictable outcomes. Fortunately, when tissue augmentation is necessary, current trends in soft tissue management demonstrate that subepithelial connective tissue grafts are the gold standard when a coronally advanced flap is created and acellular dermal graft, enamel matrix derivative, or collagen matrix is placed. The riskier proposition is placing a free gingival graft, which has been shown to disappear from the esthetic zone and is very limited, even in esthetically irrelevant applications, unless the graft is de-epithelialized.
Another way to hedge your bet? Use healing abutments with the proper size, shape, and handling characteristics. Anatomic healing abutments protect soft and hard tissues and reduce crestal-bone resorption compared to concave/straight healing abutments. The expert technicians at MicroDental Laboratories can assist with the design and use of these essential implant treatment components.
Jerry Hu, DDS, Dr. Jerry Hu is triple board certified in dental sleep medicine and holds masterships, fellowships, and accreditations in implant and cosmetic dentistry. He also has published numerous clinical studies in peer reviewed, highly respected journals such as AACD's Journal of Cosmetic Dentistry, and AADSM's Journal of Dental Sleep Medicine. Dr. Hu also teaches for Modern Dental Group both nationally and internationally, and for Sleep Group Solutions, VIVOS growth guidance appliance group, and Prosomnus Sleep Technologies. He also has won numerous awards in cosmetic and implant dentistry from Macstudio Model Search by MicroDental, and IAPA Aesthetic Eye competition. He is currently working on a patent for dental sleep medicine, and looking to help the US military out in dental sleep medicine.