A Variation of the Modified Roll Technique.pdf
- 1. The International Journal of Periodontics & Restorative Dentistry e116 Pouch Roll Technique for Implant Soft Tissue Augmentation: A Variation of the Modified Roll Technique Sang-Hoon Park, DDS, MS* Hom-Lay Wang, DDS, MSD, PhD** Postextraction ridge collapse is a common clinical challenge in con- temporary implant dentistry. The amount of horizontal and vertical ridge loss may reach up to 60% within 2 years of tooth extrac- tion,1 most of which occurs within the first year of tooth loss.2 Even in the presence of an immediate im- plant, buccolingual width collapse of the healing extraction socket has been recorded to reach up to 4.2 mm.3 This ridge loss is encountered more frequently in the absence of adequate buccal bone thickness.4 Seibert5 and Allen et al6 classified this ridge deficiency by assessing the volume of the soft tissue alone, while Lekholm and Zarb,7 Misch and Judy,8 Palacci and Ericsson,9 and Wang and Al-Shammari10 pro- posed a classification with respect to the underlying hard tissue. Soft tissue augmentation techniques may satisfactorily and predictably re-create esthetic en- hancement in mild to moderate horizontal defects, equivalent to mild to moderate type B defects6 or H-s/-m defects of HVC clas- sification.10 Many authors have This paper presents three cases of peri-implant mucosal defects that were successfully treated with a newly proposed “pouch roll” implant soft tissue augmentation technique. This procedure uses a de-epithelialized connective tissue layer during the first or second stage of implant surgery over the underlying dental implant without the need for sutures. At 2 weeks, healing was remarkable, with excellent plaque control. At 3 months, only minimal tissue shrinkage was evident. As a result, a 2- to 3-mm increase in the width of the keratinized tissue was noted around the augmented implant site. This technique is an atraumatic, versatile, and cost-effective surgical modality that enhances the peri-implant soft tissue over the ridge with a soft tissue thickness ≥ 3 mm. The pouch roll implant soft tissue augmentation procedure provides an easy and less traumatic correction of a mild to moderate buccal ridge deficiency by thickening the soft tissue around the dental implant. (Int J Periodontics Restorative Dent 2012;32:e116–e121.) * Assistant Professor, Department of Periodontics, Dental School, University of Maryland, Baltimore, Maryland. ** Professor and Director of Graduate Periodontics, School of Dentistry, University of Michigan, Ann Arbor, Michigan. Correspondence to: Dr Sang-Hoon Park, 650 W. Baltimore Street, Baltimore, MD 21201; fax: (410) 706-7201; email: sbpark1978@gmail.com. © 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
- 2. Volume 32, Number 3, 2012 e117 proposed various soft tissue aug- mentation techniques for pontic site development over a partially edentulous site. These techniques include a subgingival connective tissue graft,11–13 the roll technique or a connective tissue pedicle graft,14–19 full-thickness gingival on- lay graft,5,20 and combination onlay- interpositional grafts.21,22 Others have either adapted or modified these techniques to accomplish lo- calized ridge augmentation around dental implants during the first or second stage of surgery using a modified roll technique,15 a rolled split palatal flap,17,18 or a beveled palatal approach.23 This paper presents a “pouch roll” procedure as a variant of the Barone modified roll technique.15 The modified roll technique allows soft tissue augmentation of the buccal ridge deficiency in limited interdental space during stage-two implant surgery, whereas the pouch roll technique is indicated in single- or multiple-implant sites with a wide interdental space. The main objec- tives of the proposed technique are to enhance marginal gingival thickness for a more stable gingival margin around the dental implant and to augment a mild to moderate soft tissue deficiency on the buccal aspect of a dental implant site. The pouch roll procedure accomplishes these two objectives without the use of any sutures, resulting in mini- mal intraoperative bleeding and postsurgical discomfort throughout the entire healing phase. Method and materials The pouch roll technique was per- formed around three single im- plants in three healthy patients: two stage-two surgeries at the maxillary right first molar (Figs 1a to 1c) and maxilary right first premo- lar sites (Figs 2a and 2b) and one case of a simultaneous single-stage Fig 1a (left) A buccal mini-pedicle flap outlined the platform of the implant at the maxillary right first molar site and was 1 mm wider than the diameter of the underlying implant platform. It was then de-epitheli- alized. Fig 1b (right) Full-thickness flap eleva- tion extended to the buccal aspect of the implant site. Fig 1c (left) Mini-pedicle flap rolled under- neath the buccal pouch. Fig 1d (right) Occlusal view 2 weeks after surgery. Fig 1e (left) Occlusal view 3 months after surgery. Fig 1f (right) Clinical presentation at 4 months during the impression-taking appointment showed a maintained gingival height. © 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
- 3. The International Journal of Periodontics Restorative Dentistry e118 osteotome procedure at the max- illary left first molar site (Figs 3a and 3b). The two first molar sites presented with H-s class defects (horizontal defect, ≤ 3 mm) while the first premolar site had an H-m class defect (horizontal defect, 3 to 6 mm), according to HVC classifi- cation.10 The dental implant at the first premolar site was intended to serve as an abutment for a maxil- lary partial overdenture. There- fore, soft tissue enhancement of the marginal gingiva was deemed important and necessary. All three cases showed an altered location of the mucogingival junction as the flap was advanced coronally during either the stage-one surgery or the earlier socket preservation proce- dure (Figs 1 to 3). Under local anesthesia, bone sounding was performed to lo- cate the platform of the implant and to measure the overlying soft tissue thickness. Soft tissue thick- ness over the implant cover screw ranged from 3 to 5 mm in all cases. The pouch roll flap design includes: (1) outlining the full-thickness pala- tal mini-pedicle flap 1 mm greater than the diameter of the underlying cover screw (Figs 1a, 2a, and 3a), (2) a partial incision at the hinge portion of the created mini-pedicle flap to facilitate buccal rolling (Figs 1a and 2a), (3) de-epithelializing the mini–pedicle flap (Figs 1a, 2a, and 3a), (4) elevating a full-thickness flap and creating a pouch with an Orban knife (Hu-Friedy) to the length of the mini–pedicle flap (Fig 1b), (5) rolling of the pedicle flap into the created buccal pouch (Figs 1c and 3b), and (6) tightening of a 3- to 5-mm-high healing abutment, which secures the mini-pedicle flap without the use of sutures (Figs 1c, 2b, and 3b). For postsurgical pain control, 600 mg ibuprofen every 4 to 6 hours was prescribed to all three patients on an as-needed basis. For the patient who underwent a simul- taneous single-stage osteotome procedure, 500 mg amoxicillin was prescribed three times daily for 5 days. Except for the latter case, patients were instructed to begin brushing at the surgical site imme- diately on the evening of surgery. Mouth-rinsing with warm salt water was recommended. No postsurgi- cal mouthrinse was prescribed for any patient. Results The mild to moderate localized buccal horizontal depression and marginal gingivae around all three implants were immediately thick- ened. The final thickness depends on the thickness of the rolled mini- pedicle flap. Minimal bleeding was observed intraoperatively. A heal- ing abutment firmly secured the rolled pedicle flap within the buccal pouch (Figs 1c, 2b, and 3c). At 2 weeks, all three cases had healed uneventfully without any ev- idence of soft tissue shrinkage (Fig 1d). A 1- to 2-mm gap formed at the buccal aspect between the healing abutment and the hinge portion of the rolled pedicle flap, which was filled with soft tissue. Minimal Fig 2a H-m class defect (3- to 6-mm hori- zontal defect according to HVC classifica- tion) evident at the buccal aspect of the implant at the maxillary right first premolar site. A buccal mini-pedicle flap was ex- tended into the mucogingival junction and de-epithelialized. Fig 2b Rolled buccal mini-pedicle flap fixed with a 3-mm healing abutment. Fig 2c Three months after surgery, healing showed a 4- to 5-mm width of keratinized tissue buccal to the implant, with a marginal tissue thickness of 3 mm. © 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
- 4. Volume 32, Number 3, 2012 e119 Fig 3a H-s class defect (≤ 3-mm horizon- tal defect according to HVC classification) present at the maxillary left first molar site. The mucogingival junction was located near the ridge crest, and a mini-pedicle flap was outlined extending beyond the mucogingi- val junction. Fig 3b A 4 × 11.5-mm dental implant was placed with a simultaneous osteotome procedure. A 3-mm-high healing abutment secured the buccally rolled pedicle flap. Fig 3c The 3-month postsurgical evalua- tion revealed a 2-mm increase in keratinized tissue at the buccal aspect of the implant. plaque was present since patients were instructed to brush over the surgical site on the evening of sur- gery. The two patients undergoing the two-stage surgeries reported that there was no need for any pain medications throughout the entire healing phase. Three months of healing re- vealed mild horizontal soft tissue shrinkage with no evident loss in vertical tissue height in all cases (Figs 1e, 1f, 2c, and 3c). All cases showed a 2- to 3-mm increase in the width of keratinized tissue and a thickening of the marginal gingiva. Discussion This case report used the pouch roll technique for soft tissue aug- mentation around a dental implant during the first or second stage of implant surgery. The main goal was to correct a mild to moderate buc- cal ridge deficiency and enhance the marginal gingiva associated with the dental implant. Achieving and maintaining an adequate marginal gingiva thick- ness as well as a sufficient width of keratinized tissue at an early phase of the implant uncovery surgery is important for the maintenance of peri-implant health and esthetics. Cardaropoli et al24 prospectively measured the dimensional altera- tions of the soft and hard tissues around 11 single-implant restora- tions over a 1-year postloading pe- riod. Buccal and lingual bone loss reached up to 1.3 mm during this time. The respective mean loss in soft tissue height was 0.6 mm for the same period. Most of these changes, however, were reported to occur before loading and likely within the first 4 weeks of the im- plant uncovery procedure.3,25,26 The degree of mucosal collapse has also been reported to depend on the biotypes of the peri-implant mucosa.27,28 Therefore, transform- ing the thin to medium-thickness gingiva to a thicker biotype with reinforced keratinized tissue during the implant uncovery procedure may result in a stable peri-implant soft tissue dimension. Several procedures have been proposed to accomplish localized ridge augmentation around dental implants. For example, a free gin- gival graft or subepithelial connec- tive tissue graft might be harvested and fixed in a pouch. However, these do not enhance the thickness of the marginal gingiva. Unlike a free subepithelial connective tissue graft, a pediculated connective tis- sue design not only augments the ridge deficiency with better vascu- lar supply but also thickens the mar- ginal gingiva around an uncovered implant. The split-palatal flap18 and beveled palatal approach23 both use palatal subepithelial connec- tive tissue as the source of the pedicle flap. The Barone modified roll technique, on the other hand, uses only de-epithelialized connec- tive tissue over the implant cover screw.15 The pouch roll technique in this case report resembles the Barone modified roll technique in that they © 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
- 5. The International Journal of Periodontics Restorative Dentistry e120 both use de-epithelialized connec- tive tissue over the implant cover screw. Barone et al15 modified the Abram roll technique during stage-two implant surgery around narrow-platform implants in the lateral incisal position. Because of the limited interdental space, the authors made a sulcular inci- sion along the adjacent teeth to avoid a buccal vertical incision. De- epithelialized tissue was rolled bu- cally and then secured to the buccal flap using a fixation suture. Two sin- gle interrupted sutures were used interproximally to achieve second- ary closure. Unlike other pedicle flap techniques,14,18,23 the modified roll technique did not need a pala- tal donor site; therefore, healing without risk of sloughing of the su- perficial split-palatal flap or palatal pain was achieved. The pouch roll technique pre sents several novel features. First, there is no need for any sutures. All other soft tissue augmentation procedures use a fixation suture to secure the rolled connective tis- sue to the buccal flap. Second, the interproximal tissue is completely preserved and heals with primary intention. In contrast, other proce- dures involve a de-epithelialized interproximal area that heals via secondary intention. Therefore, the pouch roll technique is likely to have minimal or no discomfort and minimal bleeding throughout the entire healing phase. Third, because of routine oral hygiene in- stituted on the evening of surgery, remarkable plaque control was observed. Furthermore, unevent- ful healing was observed without use of a postsurgical mouthrinse. Lastly, a 2- to 3-mm increase in the width of keratinized tissue may be expected when the thick tissue is rolled buccally. Biotransformation of the thin peri-implant mucosa to a thick biotype may promote implant stability. A partial gap between the hinge portion of the mini-pedicle flap and the healing abutment was seen to be healed with keratinized tissue at 3 months. The apical por- tion of the gap, however, remained completely sealed with rolled con- nective tissue. Like all other pro- cedures reported in the literature, a limitation of the proposed tech- nique is that relatively thick overly- ing tissue (ie, ≥ 3 mm) is needed to adequately perform this procedure. Conclusion The pouch roll procedure is an atraumatic, versatile, cost-effective soft tissue augmentation proce- dure performed during either single-stage implant placement or two-stage implant surgery. This technique is indicated in the cor- rection of a mild to moderate hori- zontal buccal ridge deficiency or to thicken the marginal gingiva around dental implants during stage-one or stage-two implant surgery. An increase in keratinized tissue up to 2 to 3 mm occurred in all three cases reported. This proce- dure not only creates excellent seal- ing around the healing abutment, but also allows the institution of routine oral hygiene during healing. Acknowledgments The authors would like to thank Shiau Harlan and Weissoff Robert of the Department of Periodontics, University of Maryland Dental School, for their efforts in helping with the selection of cases and reviewing of the arti- cle. This work was partially supported by the University of Maryland Periodontal Gradu- ate Research Fund. References 1. Atwood DA. Reduction of residual ridg- es: A major oral disease entity. J Prosthet Dent 1971;26:266–279. 2. Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: A mixed-longitudinal study covering 25 years. J Prosthet Dent 1972;27:120–132. 3. Covani U, Bortolaia C, Barone A, Sbor- done L. Bucco-lingual crestal bone changes after immediate and delayed implant placement. J Periodontol 2004;75:1605–1612. 4. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone thickness on facial marginal bone response: Stage 1 place- ment through stage 2 uncovering. Ann Periodontol 2000;5:119–128. 5. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and wound healing. Compend Contin Educ Dent 1983;4:437–453. 6. Allen EP, Gainza CS, Farthing GG, New- bold DA. Improved technique for local- ized ridge augmentation. A report of 21 cases. J Periodontol 1985;56:195–199. 7. Lekholm U, Zarb GA. Patient selection and preparation in tissue-integrated prostheses. In: Brånemark P-I, Zarb GA, Albrektsson T (eds). Tissue-Integrated Prostheses. Osseointegration in Clini- cal Dentistry. Chicago: Quintessence, 1985:199–210. 8. Misch CE, Judy KW. Classification of par- tially edentulous arches for implant den- tistry. Int J Oral Implantol 1987;4(2):7–13. 9. Palacci P, Ericsson I. Anterior maxilla clas- sification. In: Palacci P, Ericsson I (eds). Esthetic Implant Dentistry: Soft and Hard Tissue Management. Chicago: Quintes- sence, 2001:89–100. © 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
- 6. Volume 32, Number 3, 2012 e121 10. Wang HL, Al-Shammari K. HVC ridge de- ficiency classification: A therapeutically oriented classification. Int J Periodontics Restorative Dent 2002;22:335–343. 11. Garber DA, Rosenberg ES. The edentu- lous ridge in fixed prosthodontics. Com- pend Contin Educ Dent 1981;2:212–223. 12. Langer B, Calagna L. The subepithelial connective tissue graft. J Prosthet Dent 1980;44:363–367. 13. Langer B, Calagna LJ. The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmet- ics. Int J Periodontics Restorative Dent 1982;2(2):22–33. 14. Abrams L. Augmentation of the de- formed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Gen Dent 1980;1:205–213. 15. Barone R, Clauser C, Prato GP. Local- ized soft tissue ridge augmentation at phase 2 implant surgery: A case re- port. Int J Periodontics Restorative Dent 1999;19:141–145. 16. Nemcovsky CE, Artzi Z, Moses O. Rotat- ed split palatal flap for soft tissue primary coverage over extraction sites with im- mediate implant placement. Description of the surgical procedure and clinical re- sults. J Periodontol 1999;70:926–934. 17. Nemcovsky CE, Artzi Z. Split palatal flap. I. A surgical approach for primary soft tissue healing in ridge augmentation procedures: Technique and clinical re- sults. Int J Periodontics Restorative Dent 1999;19:175–181. 18. Nemcovsky CE, Artzi Z. Split palatal flap. II. A surgical approach for maxillary im- plant uncovering in cases with reduced keratinized tissue: Technique and clini- cal results. Int J Periodontics Restorative Dent 1999;19:385–393. 19. Scharf DR, Tarnow DP. Modified roll tech- nique for localized alveolar ridge aug- mentation. Int J Periodontics Restorative Dent 1992;12:415–425. 20. Miller PD Jr. Ridge augmentation under existing fixed prosthesis. Simplified tech- nique. J Periodontol 1986;57:742–745. 21. Orth CF. A modification of the con- nective tissue graft procedure for the treatment of type II and type III ridge de- formities. Int J Periodontics Restorative Dent 1996;16:266–277. 22. Seibert JS, Louis JV. Soft tissue ridge augmentation utilizing a combination onlay-interpositional graft procedure: A case report. Int J Periodontics Restor- ative Dent 1996;16:310–321. 23. Shapira L, Klinger A. A beveled-pala- tal approach for localized soft-tissue augmentation at phase-2 implant surgery. Pract Proced Aesthet Dent 2002;14:170–177. 24. Cardaropoli G, Lekholm U, Wennström JL. Tissue alterations at implant-support- ed single-tooth replacements: A 1-year prospective clinical study. Clin Oral Im- plants Res 2006;17:165–171. 25. DeAngelo SJ, Kumar PS, Beck FM, Tata- kis DN, Leblebicioglu B. Early soft tissue healing around one-stage dental im- plants: Clinical and microbiologic param- eters. J Periodontol 2007;78:1878–1886. 26. Joly JC, de Lima AF, da Silva RC. Clini- cal and radiographic evaluation of soft and hard tissue changes around implants: A pilot study. J Periodontol 2003;74:1097–1103. 27. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mu- cosa: An evaluation of maxillary anterior single implants in humans. J Periodontol 2003;74:557–562. 28. Spear FM. Maintenance of the interden- tal papilla following anterior tooth re- moval. Pract Periodontics Aesthet Dent 1999;11:21–28. © 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.