lin Ora inp Res 1995: 6: 0-68 Printed Denmark ~All eights reserved Coppright © Munksgaard 1995 CLINICAL ORAL. IMPLANTS RESEARCH ISSN 0808-7161 The use of a connective tissue graft for closure over an immediate implant covered with an occlusive membrane Edel A. The use of a connective tissue graft for closure over an immediate implant covered with an occlusive membrane. Clin Oral Impl Res 1995: 6: 60-65. © Munksgaard, 1995 ‘Complete wound closure over an immediate implant is considered to be a desirable goal. This case report describes for the first time the use of a connective tissue autograft placed under the existing flap margins of an extraction socket to successfully achieve closure over an immediate implant covered with an occlusive membrane. The rationale of the method is de- scribed. Healing was uneventful and epithelization of the graft surface from surrounding tissues was achieved. This technique created an in- creased width of keratinized tissue and avoided the need to disrupt the normal anatomical relationships of the surrounding buccal tissues, in con- trast to current techniques. The advantages of the technique, together with factors that may influence healing and predictability, are discussed. A. Edel Petach Thkva, Israel Key words: connective tissue graft — flap closure — immediate implant — wound healing A. Edel, Private practice limited to Periodontics, 19 Keren Kayemet Street, Petach Tikva, Israel ‘Accepted for publication 5 May 1994 The immediate placement of an implant into an extraction site can reduce the time interval from tooth extraction to implant-supported restoration (Lazzaro 1989). However, due to the discrepancy of size and form between the extraction socket and implant, a space very often exists around the im- plant, especially in the coronal portion. Recent studies (Lazzaro 1989; Nyman et al. 1990; Becker et al. 1991) have demonstrated that the use of an occlusive membrane according to the principles of guided tissue generation can result in bone-form- ing cells populating the peri-implant space and subsequent osseointegration. The question as to whether the membrane should be covered completely or not during the re- generative period has been a topic of controversy, but a recent study in monkeys (Warrer et al. 1991) would indicate that predictable complete osseoin- tegration of dental implants placed into fresh ex- traction sockets only occurred when the membrane remained covered throughout the regenerative healing period. Primary closure can be achieved over the im- mediate implant and membrane by the method de- scribed by Bowers & Donahue (1988), using a peri- osteal releasing incision and vertical incisions to achieve sufficient mobility of the buccal flap. The buccal flap is then approximated to and sutured to the palatal flap. This technique has the disadvan- tage of moving any existing buccal attached gin- giva coronally and results in a discrepancy between the mucogingival junction of the treated site and adjacent sites. This may require correction at a later stage and can result in aesthetic problems, es- pecially if the site is located in the anterior maxilla. ‘A modified technique utilizing a rotated buccal fiap from an adjacent tooth site to achieve primary closure has been described (Becker & Becker 1990). This technique also results in a discrepancy in the mucogingival junction and also requires an adequate width of attached gingiva to be present preoperatively at the donor site. If an inadequate width of buccal attached kera- tinized gingiva does not exist preoperatively at the extraction site or adjacent areas, these techniques are severely compromised. If additional width of keratinized gingiva is desired, this requires a further procedure to be performed at some later stage. The connective tissue graft was introduced inperiodontology by the author as a means of in- creasing the width of keratinized gingiva (Edel 1975). The use of gingival or palatal connective tissue as an inductor of keratinization of prolif- erating epithelial cells has been well documented (Edel & Faccini 1977) and is a predictable pro- cedure (Edel 1974). Recently. autogenous connective tissue grafts have also been shown to be predictable for cover ing root recession (Jahnke et al. 1993) This technique requires the preparation of a par- tial thickness envelope flap at the recipient site into which is placed a connective tissue graft, a portion of which is placed on the denuded avascular root surface to be covered. The envelope flap is then sutured back over the connective tissue graft ap- proximately in its original position. Healing is usually uneventful. Induction of kera- tinization of epithelial cells proliferating onto the connective tissue from the surrounding tissue oc- curs and results in the reconstitution of all or most of the lost keratinized gingiva and root coverage. The technique affords a collateral blood supply from the replaced envelope flap that partially over- lays the connective tissue graft while a portion of the graft is localized on the avascular root surface. This report describes the use of an autogenous connective issue graft to achieve primary closure over an occlusive membrane covering an imptant placed into an extraction socket. Material and methods ‘A 62-year-old male patient was referred by his den- tist for extraction of the hopeless roots of tooth 24 and immediate replacement by an implant. The first left maxillary molar was missing, and a tem- porary bridge 24, 25, 26, 27 was present. The temporary bridge was removed and an in- trasulcular incision was made around the roots to be extracted. Granulation tissue that had grown to cover the roots was curetted (Fig. 1). The roots were extracted atraumatically and the socket was debrided. Vertical releasing incisions were made at the distal line angle of tooth 23 and mesial line angle of tooth 25 up into the buccal mucosa. A full thickness buccal flap was raised to allow the buccal bone of the proposed implant site to be visualized. An intrasulcular palatal incision was made from the distopalatal aspect of tooth 25 to the mesial line angle of tooth 23. A full thickness palatal flap was elevated to expose 3-4 mm of the palatal bone of the extraction site. A 13-mm-long and 4-mm-diameter hydroxyapa- tite (HA) coated implant (Omniloc, Calcitek, USA) was placed centrally into the socket at ap- proximately 1 mm below the height of the socket Connective tissue graft Fig. 2. Implant placed centally into the extraction socket ap- proximately I mm below the est of the ridge margin (Fig. 2). Initial stabilization was achieved, and an occlusive membrane (GTAM, W. L. Gore & Associates, Flagstaff. AZ. USA) was se- lected and trimmed to cover the defect and extend over the bony margins and thus fully cover the im- plant (Fig. 3). ‘An autogenous connective tissue graft approxi- mately 1-2 mm thick was harvested from the pala- tal aspect of the ridge of the missing first molar area as described previously (Edel 1975). Care was taken that the connective tissue graft was devoid of epithelium and of a diameter such that the pass- ively repositioned flap margins would cover it by approximately 3 mm on each side (Fig. 4). The do- nor site was sutured with interrupted silk sutures. At the treatment site, the vertical releasing in- cisions were sutured first with Teffon sutures (W. L. Gore & Associates), followed by interrupted su- turing of the buccal and palatal papillae to adapt the flap over the connective tissue graft A third suture was then placed across and super- ial to the connective tissue graft to retain it in 61Fig. 3. GTAM membrane adapted to cover the implant and extend over the bony margins of the socket Fig. 4. Connective tissue graft placed over the membrane and under the flap margins place, and the graft was gently compressed against the underlying membrane to eliminate any void. No intentional attempt was made to co-opt the buccal and palatal flaps, but some small degree of coronal displacement did occur mesially (Fig. 5). Appropriate antibiotics (amoxicillin 500 mg 3 times a day for 5 days) were prescribed together with postoperative instructions including saline mouth rinsing from the day after surgery. No sur- gical dressing was placed. The pontic area of the temporary bridge cover- ing the treated site was relieved so as to ensure no pressure and to anticipate some local swelling. Ad- ditional acrylic was added buccally and palatally to widen the pontic margins to ensure that the con- nective tissue graft area was fully tented. Results The patient was examined at day 5. Healing was progressing as expected. Some oedema of the con- nective tissue graft was observed. This appearance was in keeping with previous reports (Edel 1975: Becker & Becker 1986) (Fig. 6) The patient was instructed to use a 0.2% chlor- hexidine gluconate mouth rinse twice daily. ‘The central interrupted suture over the graft was removed at 10 days by which time considerable re- duction of the oedema had occurred, and the graft was beginning to blend with the adjacent flaps (Fig. 7). The balance of the sutures were removed at 14 days, by which time epithelization was progressing nicely. Fig. 8 shows the condition at 3 weeks. and Fig. 9 shows the appearance at 4 weeks. At this time, a small portion of the free margin of the membrane was visible through the apical part of the mesial vertical releasing incision line. The membrane had evidently been a little too wide in this area and had perforated the incision line. This was managed by local swabbing of 0.2% chlorhex- ‘ig. 5. Flaps sutured without attempt to coapt the buccal and palatal margins Fig. 6. 5 days postoperatively. Some oedema of the graft is evi- dent. Graft site sutured with Teffon sutures and donor site with silk sutures,