376

The Inlernationol Journal of Periodorlics & Restorative Dentistry


Guided Tissue Regeneration
for Implants Placed
into Extraction Sockets and
(or Implant Dehiscences:
Surgical Techniques and
Case Reports
fleeter, DOS*
on £. Becker, DD9
Guided tissue regenerotion ¡s a bio-
logic principle based on selective cell
populotion. This concept hos been
used to ottoin new ottochment in vor-
ious types of periodontal osseous le-
sions,'"^ Dohlin et al' used exponded
polytetrafluorethylene |e-PTFE or
polytef) membrones to exclude con-
nective tissue from contacting stand-
ardized defects in the mandibles of
rots. Control defects were not pro-
tected by membranes. At 6 weeks the
membrane-treated defects heoled
with bone, while mmimol heoiing oc-
curred ot the control sites. Recently,
Dohlin et ol' used membranes to re-
generate bone over dehisced dento!
• University of 5outhem Colifornio School
of Dentistry, Department of Periodonics,
ond Universily of Texas ot Houston, De-
partment of Periodontics
' University of Texos at Houston, Depart-
ment of Penodontics.
Correspondence address: Dr William
Becker, 801 N Wilmot B-2, Tucson, Ariîona
85711.
377
implants. Polytef membrones were
placed over implant dehiscences in
robbits. Membranes were placed
over implants to isolate them from
flop connective tissue ond epithelium.
Isolotion of the implants with mem-
brones creoted o spoce for dot re-
tention and bone growth. Control
sites did not receive membrane
plocement. At retrievol, the test sites
had on average of 3.8 mm of co-
ronal bone formotion, while control
sites had on averoge of 2.2 mm of
bone regenerotion.
Becker et ol' ploced titonium im-
plants into the mandibles of dogs,
Dehiscences were creoted on the fo-
cial aspects of the implants, exposing
two to three implont threads. Spe-
cially prepared polytef implant aug-
mentation materiol (Gore-Tex Aug-
mentotion Moterial, W. L. Gore ond
Associates) wos fitted over the ex-
posed threods and held in ploce with
the implant cover screw. Control sites
were not protected by membranes.
At 18 weeks the implants were ex-
posed, measured, ond retrieved. For
test sites the meon midbuccal in-
crease in bone height over the pre-
viously exposed threods wos 1.38
mm, while the change in bone height
for the controls was 0.23 mm.
Lozzaro' used polytef membranes to
cover implants placed into extraction
sockets. The membranes were not
covered by the surgicoi flops ond
were removed between 4 to 6 weeks
öfter surgen/. At the second-stage
procedure, clinicol evidence dem-
onstroted varying omounts of bone
formotion odjocent to the implonts.
Nymon et al'" reported two cases
where polytef membranes were used
for dental implants. One membrane
was ploced over an implant in an
extroction socket, while the other site
Volume 10, Number 5, 1990
 378
received a membrane far the pur-
pose of ridge augmentation. At the
second-stage procedure, bone was
present against the implant, and the
ridge appeared widened.
The concept of placing implants
into extraction sites and protecting
them vvith materials that favor bone
growth is interesting. If predictable,
this procedure may help prevent
postextraction ridge résorption, there-
by increasing the bone volume avail-
able for implant placement. Further-
more, the time necessary for com-
pletion of the restorative phase of re-
construction will be shortened. If the
alveolar crest is norrow, dehiscences
can occur during implant placement.
Exposed threads decreose the bone
volume thot supports the implant,
which may couse gingivol problems
once the implant has been exposed
and restored. Isolating dehiscence-
type defects with membranes may
selectively favor bone growth.
Membranes used for enhancing
bone formotion adjacent to dental
implants should maintain sufficient
space for clot organization and bone
formation. In order to minimize pa-
tient trouma, the membrone should
remoin covered until the second-
sfage implant procedure is per-
formed.
The Internolional Journal ol PenodonNcs & Reslorolive Dentisliy
The purpose of these case reports
is to present surgical techniques for
placing implant ougmentotion mo-
terial over dental implants. These
techniques were developed in order
to enhance bone growth over dehis-
cences and implants ploced into ex-
traction sockets. These reports pres-
ent o flap design for attaining max-
imum tissue coverage over implants
placed into extraction sockets. Fur-
thermore, a method will be described
for preventing the augmentation ma-
tenal from collopsmg ogoinst ex-
posed implant threads after flap clo-
sure, A simple method for harvesting
autogenous bone during implant
plocement will be described. If nec-
essary, this bone may be used during
implant placement. Patients treoted
by these methods will be presented
OS cose reports.
Surgical technique
A periodontal evaluation is neces-
sary prior to tooth extraction, Ploce-
ment of implonts into overtly infected
extraction sockets is controindicoted,
Maxillory and mondibulor premolars,
canines, and incisors are ideal can-
didates for extraction and immediate
implant plocement. These teeth
should hove odvonced periodontal
disease as evidenced by deep prob-
ing depth, advanced clinical ottoch-
ment loss, radiographie evidence of
bone loss, and moderate to severe
mobility. Teeth with root fractures, en-
dodontic failures, or compromised
tooth position should olso be consid-
ered for extraction followed by im-
mediate implant plocement. If there
is adequate bone over the mandi-
bular canal or inferior to the moxillaiy
sinus, molar sites may also be can-
didates for extraction and immediote
impiont placement.
In the mandibular arch there
should be a minimum of 3 to 4 mm
of bone inferior to the root apex and
coronal to the mandibular canal. In
order to stobilize the implant in the
moxillary orch, there should be suf-
ficient bone superior fo fhe root apex
and inferior to the maxillary sinus.
Once the decision has been made
to extract the tooth and to place an
immediate implant, the patient must
be counseled on the risks and ben-
efits of such procedures.
The patient is prepared for surgery
in the usual manner, and an appro-
priate local anesthetic ogent is od-
ministered. Figures l a to g show the
surgical technique for plocing im-
plants in extraction sockets. Prior to
extraction, the gingiva should be de-
tached from the tooth, A surgical el-
evator can be used to corefully luxote
 379

Figs to to g Diagrams represent ftap design for placement of an imptant inta an extraction socket.

Fig ta Initiât incisions odjocent to a moxitlary premotor. tnci- Fig Ib Buccal and palatal flops hove been rejected.
sions are extended one tooth anterior lo the tooth to be ex-
tracted. Note vertical incisions.

Fig tc The implani has been placed superiar to Ihe apicat Fig td A titonium washer has been placed on top of the im-
extension of Ihe extraction socket. plant. This will keep the material fram collapsing against the
imptont once the flaps ore sutured

Volume 10, Number 5, 1990

 380

Fig le impiant augmentatian material has been fixed ta the Fig If A pedicle flop from the canine has been rotated dis-
implant with a cover-screw. tally and completely covers the implant The flops ore sutured
with vertical mattress sutures

Fig tg The flaps adjacent to the implant are sutured.

The Inteinolioiiat Jojmol ot Penodonlics & Restorafive DerBslry


the tooth from its socket. The tooth
should be mobile before it is re-
moved. These steps are importont
because fracture of the buccol or lin-
gual alveolar plates moy jeopordize
implant plocement.
Placement of multiple implonts ot
one visit requires odequate surgical
access. A buccal horizontal incision
is made 2 to 3 mm opicol to the
mucogingival junction and on ade-
quate distance distal to the extraction
site. This incision is mode to bone.
The horizontal incision is joined by a
vertical incison at the distal aspect of
the extraction socket. Using sulculor
incisions, the palatal flap is extended
from the distal aspect of the extrac-
tion site to the mesiol aspect of the
adjacent tooth. A veh^ical releasing
incisian is made at the mesiopolotol
line angle. On the distal buccal flap
ospect, intrasulcular incisions are ex-
tended anteriorly to the mesial aspect
of the adjacent tooth A ven"ical re-
leosing incision is made at the me-
siobuccal line angle ond is carried
into the vestibule by partial thickness
dissection. This incision vyill releose
tension on the flop so it con be ro-
tated over the extroction site. The
buccal and polotol flaps are reflect-
ed to goin occess for implant place-
ment. The extraction socket should be
debrided of granulation tissue. Var-
ious straight instruments can be used
to explore the depth and direction of
the socket. In the maxillary premolar
region the polotal root is usually cho-
sen as the implant site. The site is
properly prepored, extending the ap-
ical aspect of the socket a minimum
of 3 to 4 mm. When the drills are
removed from the site, bone lining the
drill flutes should be horvested with o
sterile instrument and pioced in small
container. This bone may be used
during the implont procedure. The
anatomy of the site will dictóte
whether a countersink is possible. If
possible, a countersink is prepored
within the bone.
Once the site hos been prepared,
the implant is pioced in the extraction
socket. It is not necessary to pretap
the site before placing the implont.
Once the implant hos been pioced
it should be evaluated for stability. An
implant placed into on extraction
socket must be immobile. If implant
threads are exposed or part of the
buccal or lingual plates have been
destroyed, placement of implant
augmentation material should be
considered. The moterial is manufac-
tured from expanded polytef and
consists of a loosly woven outer
structure ond a tightly woven inner
structure. The outer portion of the ma-
teriol will allow tissue integrotion,
whereas the inner portion is occlusive
ond minimizes cellular penetration.
Augmentation material is placed
over the implant to protect the ex-
posed implant threods from flap con-
nective tissue, thereby allowing bone
to grow onto the exposed implant
surface.
381
The material can be placed over
the defect and held in position by
coreful flop apposition, or it con be
fixed to the implant with the cover
screw. Early experience with dehis-
cence-type defects showed o tend-
ency for the material to collapse
against the implant surface. Mainte-
nonce of the spoce adjacent to the
implant is critical for clot protection
and ultimately bone grovAh. There-
fore a method to maintain space
once the materiol was fixed to the
implant was needed. Commerciolly
pure titonium washers were manu-
factured as a custom device. These
were prepared in 5-mm and 5.5-mm
diameters. The inner diometer of the
washer is 3 mm, and they are 0.4
mm thick. The wosher extends over
the implant and prevents collapse of
the motenal against the implont once
the flaps have been sutured. The mo-
terial is extended a minimum of 3 to
4 mm lateral to the borders of the
implont and 3 to 4 mm opicol to the
exposed port of the implant. The cor-
ners of the material should be round-
ed in order to keep the edges from
perforating the flap. Once the ma-
terial is shaped, o rubber dam punch
is used to make a small hole in the
material. The washer is placed over
the implant, and the material and
washer are fixed to the implont with
the cover screw.
The buccal flap from the tooth an-
terior to the extraction socket is re-
laxed from the periosteum by sharp
dissection and is rotated distally. Re-
sistance to distal pedicle plocement
should be relieved by sharp dissec-
tion. The flap should be passively
placed over the extraction site and
sutured with a combination of vertical
and horizontal mattress sutures. There
should be minimum suture tension on
• 10, Number 5, 1990
 382
the flaps. This method of suturing ev-
erts the flap morgins.
Once the flops have been sutured,
a porfió I-thick ness Ioteroiiy posi-
tioned flop is token from the odjocent
tooth. The pedicle flap is used to cov-
er the roof odjocent to the extraction
site. If anatomy or other limitotions
preclude covering the donor site, the
oreo con be ougmented with o soft
tissue autogroft at o later date.
The potient is given appropriote
posloperotive ontibiotics, onolgesics,,
and instructions. The patient is seen
in 24 hours for wound inspection, and
in 1 week the sutures ore removed,
Ideoliy, the material should remoin in
place for the entire heoiing period.
During the first 4 to ó weeks of heoi-
ing, the cover screw and moteriol oc-
cosianolly become exposed. If there
is gingival inflammation ond material
exposure, the area should be ones-
thetized and a partial-thickness flap
should be reflected in order to re-
trieve the augmentation moteriol. The
cover screw is removed and the
wosher ond material ore gently re-
moved from the underlying gronulo-
tion tissue. The gronulotion tissue thot
has formed beneath the material
must not be probed or removed. The
cover screw is replaced and the flaps
are sutured.
The Intemolionol Jojmol of Periodontics & Reîloraiive
Case reports
The following ore reports of patients
who were treated using the surgical
techniques and methads described
above. These potients ore port of a
multicenter study and the results will
be reported in the future.
Cose '
An endodonticoliy treated moxiliary
left first premolor hod a short root
ond was fractured at the gingivoi
morgin (Figs 2 and 3). The tooth was
considered to have o poor prognos-
is. During the treatment planning
phose of theropy it was decided to
remove the maxillary first premolar,
place an implant into the extraction
site, ond place one odditional im-
plont distal to the extraction site. The
patient was anesthetized ond the first
premolor was removed.
[ndsions were mode as described
previously. After flap reflection ond
socket debridement, the site was ex-
amined. The buccal plate of the ex-
troction socket was inferior to the al-
veolar crest, and the palatol bone
wos intact. The extraction socket wos
deepend 3 to 4 mm beyond the op-
icol extension of the socket. A 15-
mm stondard Brônemarf<® implant
(Nobelphorma USA Inc) was ploced
into the prepored site and wos im-
mobile after implont installotion ¡Fig
4), On the buccal ospect eight
threads were exposed (4.8 mm],
while on the palatol aspect there wos
o 2-mm spoce between the implont
and surrounding bone. A piece of
augmentotion materiol was shaped
to cover the exposed threods. The
moteriol wos extended 4 to 5 mm
laterally and polotally beyond the
implant margins. A rubber dam
punch wos used to make o smoll
hole in the material, after which the
moteriol wos fixed to the implont v/ith
the implont cover screw ¡Fig 5).
The flop from the canine was ro-
tated over the material and sutured
(Fig 6). The potient was given appro-
priate onalgesics and ontibiotics. The
wound was exomined for closure in
24 hours ond the sutures were re-
moved at 7 doys.
At 4 weeks a smoll area of the
cover screw became exposed. By 6
weeks the cover screw wos exposed
and the odjocent tissues were mod-
erotely inflomed (Fig 7). The patient
was onesthetized and the material
was removed ¡Fig 8), There wos o
large moss of gronulotion tissue cov-
ering the areo beneath the moterial
(Fig 9); this tissue wos not disturbed,
and the flops were sutured (Fig 10).

Fig 3 Preaperatwe radiograph of maxil-
lary left first premolar
Fig 4 The firsf premolar has been re-
moved and on implant has been placed
inta the extractian sacket Note the ab-
sence of bone aver the buccal aspect of
the implant and the wide osseous well an
the polatal implant aspect. There are
eight exposed threads.
383
Fig 2 Preoperaiive photograph of a
maxillary left first premolar. The crown he
been fractured at the gingival margin.
Fig 5 Implant augmenlalian material
hos been secured ta the implant with the
cover screw
10, Number 5, 1990
 384

Fig 6 The flaps hove been sutured aver Fig 7 At 6 weeks the cover screw was Fig 8 A partial-thickness ftap was re-
the implant sile. Note complete soft tissue exposed. ftected in order to retrieve the augmenta-
coverage of material-augmented implant tion material

Fig 9 ¡tefti Granulation tissue was

beneath the augmentation material
This materiat must not be disturbed

Fig 10 (right! The partiat-thickness ftap

has been sutured to the adjacent tissues.

Fig 11 ¡left! At 8 months a futf-thickness

flap has been elevated, exposing the
implant. Note the bone growth over Ihe
previousty exposed implant threads. Two
threads remain expased.

Fig 12 ¡rtghtl Radiograph af restored

impfonts. Radiograph taken 14 months
atter imptant foading.

The Intemalianal Joumol of PeriodonHcs S Restoralive DertUhy


Tfie second-stage implant proce-
dure was performed 8 months after
implant insertian. Canventionally
plaeed implants in the maxillary arefi
are usually uncovered after ó months
of healing. Because this was a new
procedure and maximum bone for-
mation was neeessary, it was decid-
ed to waif 8 months before uneav-
ering tfie implant. Under loeal anes-
thesia, a partial-tfniekness flap v/as
raised over tfie implant in the extrac-
tion site. After careful implant exam-
ination, tfie partial-thiekness flap was
stripped off tfie underlying perios-
teum, exposing tfie underlying bone.
Tfie previously absent buccal alveo-
lar plate fiad almost completely re-
generated, and ó of the 8 initially ex-
posed implant tfireads were covered
with bone. Tfiere wos a 3.6-mm in-
crease in bone heigfit [Fig 11). Al-
tfiough tfie widtfi of tfie adjacent al-
veolar n'dge was not measured, it ap-
peared ta have increased.
The remaining implant was ex-
posed and appropriate abutment
eyiinders were plaeed. An implant-
supported fixed partial denture was
fabncated- Radiographie and clinical
evidence indicate tfiat the implant
placed in tfie extraetion socket as
well as the distal implont were inte-
grated withi bone ¡Fig 12}.
385
Cc
Three implants were placed in the
mondibular anterior region. After im-
plant placement, one of the implants
had a 3-mm linguol bone dehis-
cence [Fig 13). The defeet was 3 mm
wide. A pieee of polytef material was
fitted to cover the defeet |Fig 14). The
material was punehed and fixed to
the implant with the cover serew. The
flops were sutured with a combina-
tion of horizontal and vertical matress
sutures. Postoperative healing was
uneventful. After 5 months a radio-
graph was taken [Fig 15). The im-
plant hod apparently healed with the
surrounding bone. The patient was
anesthetized and the implants were
exposed with ful I-thickness mueo-
periosteal flaps.
The augmentation material ad-
hered firmly to the underlying bone.
Removal of the membrane from the
bone was aeeomplished by shorp
disseetion. Inspection of the area
demonstrated that bone had cov-
ered the previously dehisced implant
[Fig 1Ó). The amount of new bone at
the midlingual probing site was 3
mm. Abutment cylinders were at-
tached to the implants. The restora-
tion comprised o bar and overden-
ture. The implants have been in fune-
tian for 4 months.
10, Number 5, 1990
 38Ó
Fig 13 Lingual 3-mm dehiscence adja-
cent to a mandibular implant.
Fig 15 Radiogroph af implant taken at
the 5-monih second-stage procedure.
Tiie Internotional Joumol of Penodontits & Restorative Dentistry
Fig 14 Augmentation material has been
adjusted to caver the dehiscence and is
held in place with the caver screw.
Fig 16 The material has been partially
remaved from the adjacent bane Nate
complete bone growth over area af pre-
vious dehiscence.
Case 3
Implonts were placed in the mondib-
ular anterior region At the time of
plocement the alveolar crest wos
considered to be nan'ow. During the
drilling procedures, outogenous bone
was horvested from the drill flutes.
After an implant was placed in the
right conine orea, it was noted that
there was a 3-mm bone dehiscence
on the buccal surface of the implant
(Fig 17). A piece of augmentation
material was shoped to cover the de-
hiscence. A titanium washer and
augmentation material were fixed to
the implant with ihe cover screw (Fig
18]. Autogenous bone shovings were
packed around the exposed implant
threods, and the moterial was adopt-
ed to the adjacent bone (Figs 19 ond
20). The flops were sutured with ver-
tical and horizontol mattress sutures,
ond the postoperative course was
uneventful [Fig 21). The sutures were
removed at 7 doys. At the 5-month
second-stage implont procedure, the
ridge odjacent to the implant op-
peared to have v>^dened ¡Fig 22).
A partial-thickness flap was made
over the crest of the ridge, and buc-
cal-lingual flops were reflected. There
appeared to be a thin membrane
over the implont. This membrane was
removed in order to expose the ma-
terial. The cover screw and wosher
were removed and the membrane
was dissected from the underlying
bone (Figs23and24).Thebonewas
coronal to its original position and the
adjacent ridge appeared to hove
widened ¡Fig 25). Removal of this
bone was necessary to place the
abutment cylinder (Fig 26]. Figures 27
and 28 ore the radiographs taken
before the second-stoge procedure
and öfter the abutment cylinder con-
 387

Fig IB (abave) Titanium washer ond

augmentation moteriol prior to placement
aver dehisced implont.

Fig 17 ¡left) After implant placemen!

there was a 3-mm labial dehiscence.

Fig 19 PlacemenI af autogenous bone Fig 20 Moterial has been adjusted to Fia 21 Flaps hove been sutured to com-
chips over exposed implant threads cover exposed threods and adjacent pletely caver implant and augmentatian
bone. material

Fig 22 Saft tissue ot 5 man&is. Note

opporent widening af ridge odjacen! to Fig 23 Exposure of moteriol at second- Fig 24 Caver screw has been remaved
the augmented implant stage procedure to expose titanium washer

'4ÉÍ

Volume 10, Number 5, 1990

 388

nectlon. The flaps were sutured and

the bone was fixed in 4% formalin
and submitted for histologie process-
ing. The implants were connected by
o tissue bar, and a mandibulor over-
denture was constructed The im-
plants have been in function for 4
months.
Histologie evaluotion of the mo-
terial ond bone proved interesting.
Bone was present within the material
¡Fig 29}. This bone could hove oc-
tually formed within the material or
may hove adhered to the material
during the removal procedure, Evoi-
uotion of the biopsy indicated pres-
ence of woven bane, osteoblostic
formation, and osteocytes within their
lacunae (Fig 30], The bone was
stained with Dohl's coldum stoin Fig 25 Bone has grown coronal to im- Fig 26 In order lo ploce the abutment
plant Fixture head is beneath marginal cylinder il wos necessary lo remove bone
[which is specific for colcified mate- bone. adjacent lo the impiant.
riols), hemotoxylin—eosin, and Mili-
can trichrome.

Fig 28 Abutment cylinder has been

Fig 27 Radiograph prior to implant un- ploced after adjacent bone was re-
covering. Note bone level and its rela- moved. Implant restored with a bar and
tionship to the titanium washer overdenlure.

The Inrerrotionol Joumol of Periodontics S. Restorotive Dentistry

 389

Case 4

The mandibular tight second pre-

molar had o vertical root fracture and
wos given a poor prognosis ¡Figs 31
and 32]. After administrotion ot local
anesthesia, intrasulcular buccal and
lingual incisions were made from the
mesial ospect of ihe second molar
lo the mesial aspect of the first pre-
molar. Vertical incisions were mode
at Ihe mesial aspect of the first pre-
molar and buccol and lingual flaps
were reflected. The second premolor
was removed and the socket was
cureled. The sockel was deepened,
ond a 13-mm standard Brânemark
implant was inserted in the socket (Fig
33). The implantwas immobile. Three
Fig 29 Bone adhering directly to augmentation motenal. implant threods were exposed. Be-
cause ihe lingual alveolar cresl was
superior to the buccal cresl, it was
decided lo overlay the ougmenlation
material over the implant (Fig 34¡,
The discrepancy in the linguol-buccal
cresl provided sufficient space for clot
retention. The tissue from the first pre-
molar was rotated distally and su-
tured over the implant (Fig 35j. A por-
lial thickness pedicle flap was taken
from the faciol aspect of the canine
and rotated lo the focial aspect of
the first premolor. The pedicle flap
was held in place with 4-0 silk ond
Dexon sulures. At ó weeks ihe im-
plont and augmentation material re-
mained completely covered by soft
tissue |Fig 36j. The secand-stoge im-
plant procedure will be completed
after 5 months of heoling.

Fig 30 Biopsy of bane removed from

coronal and lateral aspects af implant
Note woven bone witfi osteobiostic activi-
ty and osteocyles wilhin their tacunae.

Volume to. Number 5, 1990

 390
Fig 31 Radiograph of the mandibular
right second premolar suspected af hav-
ing a raat fracture.
Fig 34 The materiol has been averlayed
onto the implant.
nal ot Penodontics & Reslorotive Denlislry
Fig 32 Nate vertical root fracture on la-
bial aspect af the mandibular right sec-
ond premolar
Fig 35 The buccal flap from the first
premolar has been rotated distally and
sutured over the Implant with vertical mot-
tress sutures. A partial thickness pedicle
flap was taken from the canine ond
rotated to the first premolor.
Fig 33 A l3-ni:-:i Sianemarl. impiuril tios
been inserted into the extractian sacket.
Fig 36 Note complete soft tissue heating
over the augmented implant This implant
will be uncovered after 5 rnanths of heal-
ing

Discussion and Summary
This report applied the principle of
guided tissue regeneration to im-
plonts placed into extraction sockets
and for the treatment of implant de-
hiscences. The purpose of this report
was to present surgicol techniques for
enhoncing bone regeneration after
implant placement. A surgical tech-
nique is described that offers the pos-
sibility for ottoining flop coverage
over implonts which have been
placed in extraction sockets and
augmented with polytef moteriol.
In order to reduce the possibility
of postoperative infection and in-
flammation, it may be importont to
attain complete flap closure after im-
plant placement. Ideally, the surgicol
sites should remain covered until the
second-stage implant procedure. If
the moterial becomes exposed dur-
ing healing, it should be removed be-
tween 4 ond 6 weeks. There have
been cose reports on the use of aug-
mentation material to cover implants
placed in extroction sites. Lozzora'
left the materiol exposed for 4 to 6
weeks. The materiol was stabilized by
placing sutures across the material.
The sutures were onchored in the
buccal ond polatol flops. Nymon et
ol'° reported complete healing after
placement of moterial over on im-
plant that was pioced into an ex-
traction socket. Soft tissue coverage
of the material was maintained for
the 6-month healing period.
We feel that, where possible, the
moteriol should be fixed to the im-
plont. This facilitates flop closure by
immobilizing the moterial and may
prevent moterial displacement during
suturing. These factors may minimize
soft tissue inflammation during heol-
ing.
Titonium woshers were used to cre-
ate and maintain space between im-
plants and augmentation material.
The titonium woshers are eosy to use,
ore retreivoble, and offer a simple
method for maintaining space adja-
cent to a materia I-augmented im-
plont. The woshers ore not reused. A
biopsy of bone adjacent to a ma-
terial-augmented implant provides
evidence of new bone formotion.
These case reports hove demon-
strated that the principle of guided
tissue regenerotion may have impor-
tont applications to implant dentistry.
Ackn owledg ment
The authors wish to thank Drs Leonard Tib-
betts and Ulf Lekholm for their help with the
preparation of this poper.
391
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Volume 10, Number 5, 1990