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2.4.3.1 Soft tissue findings

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Soft tissue quality and quantity are important criteria for a successful bone grafting procedure. A thin soft tissue biotype as well as scar tissue represent a high risk of tissue necrosis, with exposure of the grafted bone. Especially after several surgeries and in cases of previous surgical procedure failures, bad vascularized scar tissue occurs on the soft tissue. Particularly, in infection cases with augmentation procedures using biomaterials, the xenogenic bone substitute material remains in the connective tissue, making a flap preparation very difficult and significantly reducing the vascularity of the tissue (Fig 2-10a to c). Therefore, in the case of severe scars, it is advisable to improve the quality of the soft tissue through the removal of all biomaterial from the soft tissue and subsequent grafting of the palatal connective tissue at least 2 months prior to the hard tissue augmentation. The use of a tunneling technique in case of vertical bone augmentation will reduce the risk of tissue necrosis and bone exposure (see Chapter 3 on the soft tissue).


Fig 2-9a Generalized oligodontia with poorly developed alveolar process and loss of vertical dimension.


Fig 2-9b Persistent primary teeth with multiple aplasia.


Fig 2-9c Plan to increase the lost vertical dimension.


Fig 2-9d Elevation of the bite by vacuum-formed stents in the shape of the definitive fixed prosthesis.


Fig 2-9e Preoperative panoramic radiograph.


Fig 2-9f Strong atrophy of the mandible after extraction of the primary teeth.


Fig 2-9g Clinical situation after bone augmentation with a bone graft harvested from the chin area.


Fig 2-9h Extension plastic in the maxillary right jaw with a bone block from the chin area.


Fig 2-9i Clinical situation 13 years after implant prosthetic restoration.


Fig 2-9j Panoramic radiograph 13 years postoperatively.

The soft tissue situation may also be limited by increased nicotine consumption. Also, systemic diseases that affect the blood circulation such as unadjusted diabetes mellitus with HbA1c values above 8% can lead to wound healing disturbances.80 Therefore, it is important to evaluate the structure of the soft tissue in the planned surgical site in order to take into consideration the number and course of any previous surgery or internal medical factors. Inflammatory symptoms should be treated as part of a systematic periodontal treatment prior to bone augmentation.

In the case of oral mucosal changes, these should first be clarified, as a leukoplakia must be assessed as precancerous.95 A soft tissue change, which is judged inconspicuous during tooth extraction, may recur after superficial removal, as it may be an epulis gigantocellularis.74

Bone and Soft Tissue Augmentation in Implantology

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