Personalization of Flap Design in the Aesthetic Zone
Rubio Nicolas DDS, Treviño Santos Alejandro DDS, MSc
Scholarship Center ITI - UNAM, Postdoctoral and Research Division
INTRODUCTION: Surgical approaches in the aesthetic zone should vary according to specific needs of every patient. When treating multiple esthetic and biological problems, personalization of flap design can reduce surgical stages and morbidity while improving overall outcomes.
A clear example of the need of of flap personalization is the necessity of combining bone augmentation procedures following implant placement and mucogingival surgery. For the means of explaining this philosophy, a case is presented.
MATERIALS AND METHODS: A 23 years-old female patient with no systemic conditions was treated for tooth lost after trauma and adjacent gingival recessions in the aesthetic area (Fig. 1). CBT showed rests of apicectomy treatment previous to extraction (Fig. 2). Bone condensation was indicated following Straumann SLActive implant placement and GBR (Fig. 3).
Personalization of flap design: only one oblique release incision distal to the canine was made with partial thickness to avoid injuring periosteum with consequently scar development. Horizontal incisions were traced with partial thickness to establish new surgical papillas and a full thickness horizontal incision was made at the edentulous ridge, 2mm buccal to the crest in order to provide a back for the flap to rest. Said incisions were connected with intrasulcular incisions (Fig. 4). A combined split-full thickness flap was prepared extending to the MGL to improve vascularization (Fig. 5). Tunneling continued towards midline for disinserting frenulum to reduce flap tension. Once flap design was completed periapical rests were removed with a Molt curette. A NC Bone Level implant was stabilized between cortical walls (Figs. 6-7) and bone augmentation was performed using 0,5cc of bovine bone and a long-term absorvable collagen membrane (Fig. 8). Denuded roots were planned only at exposed level + probing depth (CAL) and EDTA (PrefGel) was applied over dry surface to condition dentinal tubules. Anatomic papillas were deepithelized with scissors or blade. Flap release was made by disinserting muscles both from periosteum attachment (blade parallel to bone) and mucosa attachment (blade parallel to mucosa). Suturing commenced at vertical incision, in an apical-coronal direction (Fig. 9). Sling sutures helped to adapt gingival margin 1mm coronal to the CEJ (Fig. 10).
No solide alimentation or brushing the zone for 1 month was indicated. Afterwards, a roll-technique was recommended. Controls were made at 1-2-4-8-12-18 weeks (Fig. 11). Residual buccal collapse appeared at 8 weeks time. A new CBT confirmed success of the GBR and at least 2mm bone width at the buccal aspect of the implant (Fig. 12). Second stage was then performed by deepithelizing crestal gingiva to roll the tissue (Fig. 13-14).
RESULTS: 20 days after second stage, restorative treatment was feasible to begin (Fig. 15). Adjacent teeth showed no bleeding, probing depth of 1,5mm or less, excellent plaque control and no residual recession. Complete root coverage was maintained in both teeth 7 months later.
CONCLUSIONS: The personalization of flap design involves a variety of surgical approaches attempting to improve all particular needs of the implantation area and its surroundings. The correct diagnosis of these areas, involving multidisciplinary assessment, helps to plan a correct flap design. This philosophy stands for the major esthetic resolution with minimum interventions.