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8 CASE STUDY lingually with a holding suture to prevent any movement (Fig. 13) . To provide addi- tional support of the soft tissue healing, a layer of autologous fibrin is placed over the augmentation material, a process that has been demonstrated to result in better integration and regeneration of the soft tissue (Fig. 14 and 15) [15]. The wound is then closed using micro- surgical technique. In our opinion, this is the most important step in the procedure along with the flap design because only a clean suture that is absolutely free of tension can achieve the desired outcome. We already prepare for this during the flap formation where the periosteum is split at the sites of the full-thickness flap. The split sections mesially and distally result in a highly elastic flap, which ensures that we can cover the large area of augmentation material without any tension. We inten- tionally implement this step early so that there is no heavy bleeding shortly before suturing as this always results in signifi- cantly impaired healing and irritation. If possible, vertical releasing incisions should be omitted during flap formation to pre- serve maximum blood supply [10,11]. The flap is firstly fixed with two deep horizon- tal mattress sutures using a polytetrafluo- roethylene suture material (Cytoplast) so that both wound edges already lie over one another without any tension (Fig. 16) . Subsequent wound closure is carried out using simple interrupted sutures with a monofilament suture material (6 – 0 Sera- lene) (Fig. 17) [3, 4]. We remove the sutures after 10 days. At this point the site is always completely free of irritation and has well healed soft tissue (Fig. 18) . We usually expose the implant after six months. We know that keratinized gingiva of adequate thickness around the implant is essentially responsible for the long-term success of the implant. For this reason, free mucosal grafts continue to make up a large part of our therapy [21]. Even prior to the exposure, it is apparent that the minimum band of 3 mm of keratinized gingiva required around the implant cannot be achieved with a simple apically positioned flap [5] (Fig. 19) . Apical position- ing alone would also thin the flap out a great deal, which in turn makes the gingiva less robust and increases bone resorption [18]. This is why we start with apical fixation of the mobile gingival sections of a split-thickness flap deep in the vestibulum to prevent subsequent movement of the peri-implant soft tissue (Fig. 20) . After removal of all mobile sections, only the periosteum and a thin layer of connective tissue remains over the augmentation material. During the exposure, narrow, cylindrical healing caps are screwed onto the implants. A free mucosal graft of sufficient thickness is lifted from the palate after measuring and fixed in a stable position and with a precise fit using simple interrupted and cross-stitch sutures (Fig. 21) . The perios- teum and connective tissue left attached provide nutrients to the transplant; these nutrients are provided solely by diffusion in the first three days. The close contact between the transplant and the recipient bed is important so that the revasculariza- tion can occur rapidly for the subsequent supply of nutrients to the free transplant [23]. The harvest site on the palate is always covered by a dressing plate to stabilize the coagulum and to also protect the wound against exogenous factors. Af- ter three weeks the transplanted tissue can barely be differentiated from the surround- ing tissue; at this point the narrow healing Fig. 10: A mixture of autologous bone, BioOss, and PRGF produces a very easy to handle matrix. Fig. 11: With the bone mixture the jaw bone was augmented both vertically and horizontally. Fig. 12: The occlusal view shows the perfectly adapted aug- mentation material around the implant in regio 35 and 36. Fig. 16: Using two horizontal mattress sutures, the flap was fixed so that the wound margins lay on top of one another free of any tension. Fig. 17: The additional wound closure was done using simple interrupted sutures with a monofilament suture material of size 6-0. Fig. 18: On removal of the sutures after ten days, the site was free of irritation with well healed soft tissue.