Sourav Chowdhury1, Chandan Kumar Karar2, Dharvind Kumar Singh2, Dipanwita Dutta3, Garima Singh1, Dipti Singh4, Sudhanshu Agrawal1*
1Department of Periodontology, Chandra Dental College & Hospital, Barabanki, India
2Department Of Oral Pathology, Awadh Dental College and Hospital, Jharkhand, India
3Department of Endodontics, Chandra Dental College & Hospital, Barabanki, India
4Department of Oral Medicine and Radiology, Chandra Dental College & Hospital, Barabanki, India
*Corresponding author: Sudhanshu Agrawal, Department of Periodontology, Chandra Dental College & Hospital, Barabanki, India.
Citation: Chowdhury S, Karar CK, Singh DK, Dutta D, Singh G, et al. Roll Flap Technique to Enhance Buccal Gingival Thickness and Implant Emergence Profile: A Case File. J Oral Med and Dent Res. 4(2):1-8.
Received: December 15, 2023 | Published: December 29, 2023.
Copyright© 2023 by Chowdhury S, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Several techniques have been developed to enhance the buccal gingival breadth, gingival height and contour surrounding the implant. In this case file, a buccal rotational flap was used to improve the buccal emergence profile of implant site and increase gingival tissue thickness. This case involves the use of a rotational flap during second-stage implant surgery performed after 3 months of implant placement, with the use of a modified healing abutment to attain a thick gingival collar.
Rolling of flap; Emergence profile; Atraumatic extraction; Immediate implant
The placement of an implant requires comprehensive knowledge of anatomy. It requires evaluation of tissue breadth, tissue height and the healing process, along with good surgical skills . The ideal need of tissue around the implant is thick attached keratinized gingiva . An adequategingivalattachmentlevel, the existence of interdental papillae, and the contour of the crown are mandatory for achieving a healthy periodontium around the implant [3-4]. Several techniques have been applied to improve the soft tissue profile around the implant, such as the AlloDerm roll technique, along with or without connective tissue grafts [5-7].
Connective tissue grafts serve a good for achieving adequate gingival thickness and increasing gingival level but do need a second surgical site. They fail to provide color match with the receptor site and sometimes result in tissue shrinkage and necrosis even though done with high professional skills [9-12].
The roll technique is used to enhance the gingival margin thickness when the defect is smaller than 3 mm. This technique has been found to be useful in second stage surgery to improve the buccal contour and tissue breadth around the implant [10-13]. The roll technique has many advantages and disadvantages. Advantages are the roll techniques helps in achieving a better emergence profile, with less scar tissue formation, more stable gingival margin, with no secondary site of surgery, maintains the blood supply to the rotated part, shorter healing period and faster tissue maturation, no need for advanced professional skills, cost effective and tissue harmony around the implant. While disadvantages are that it does not change the gingival biotype, tissue loss may occur at the implant site, not applicable for multiple implants, does not improve the interdental papillae level and it may leave a scar at the esthetic zone .
A 35-years old patient came in OPD of Chandra Dental College and Hospital, Baranski (UP) with a non-restorable decayed root 46. Treatment steps was explained and discussed with patient which included removing the retained root and placing an implant to allow for soft and bony tissue healing. After an atraumatic extraction of the retained root, an immediate implant was placed; a full-thickness envelope was raised with the adjacent papillae. Bone recontouring was done as per selected size of implant, and an implant 12 mm in length and 4.5 mm in diameter was placed. The implant was placed with moderate stability (torque 40 Ncm). The cover screw was placed, the flap was approximated, and the implant was completely covered. The implant was left to heal for 3 months, after which soft tissue and hard tissue was evaluated clinically (Figure 1a) and radiographically (Figure 1b) for re-entry surgery. Second surgery was performed by raising a three-sided flap that excluded the adjacent papillae. A buccal crestal incision was made, the cover screw was removed, and a modified healing abutment with a gingival collar with of flowable composite was prepared. The modified healing abutment was small in shape (diameter and length) with open contact with adjacent teeth to allow soft tissue growth and thickening. The healing abutment was torqued into place.
One of the most important steps is the proper de-epithelialization. So, de-epithelization with done with B.P. blade no 11 and enabling the flap to berotated inward and was adapted with the keratinized mucosa facing the healing abutment (Figure 2) and simple interrupted suturing was performed to fix the rotated flap buccally against the abutment (Figure 3). The healing abutment was ensured to be kept out of occlusion during centric movement and excursion. Patient was recalled after 1 week and on examination healing was evaluated.
After one month, the treated site was evaluated with complete soft tissue maturation, to reveal an excellent emergence profile (Figure 4). The modified healing abutment was then removed (Figure 5), perfect thick gingival collar was attained and impression coping was screwed into the implant temporarily to make an impression. The permanent crown was placed, excess cement was removed, and occlusion was adjusted. The patient was seen again after 3 months, at which time the papillae were almost filling the interdental space and the scar was faded (Figure 6).
Figure 1a: Clinical image.
Figure 1b: Radiographic Image of healing after 3 months of extraction of retained root 46 and placement of an immediate plant.
Figure 2: Second stage surgery is performed 3 months after implant placement and buccal rotational flap performed simultaneously with a modified healing abutment with flowable composite. A three-sided flap with a more lingually placed crestal incision and the papillae reserved is created. After de-epithelization with scalpel, two vertical incisions are made to the vestibule so that the flap could be freely rotated.
Figure 3: Suturing was performed buccally to fix the rotated flap against the abutment.