Managing cases

In the first case described by the chair, a good approach could be to perform soft tissue augmentation first, and then during a second procedure place the implant and perform GBR simultaneously.

Zucchelli thought that a simultaneous sub-marginal connective tissue graft could be simpler and better for the patient. Buser said he would perform GBR and implant placement simultaneously, achieving primary closure and covering the implant with the membrane. Then he would re-evaluate the case at the time of implant uncovering. It was suggested that the minimum width of keratinised mucosa would be 3mm. If there was any less, the case couldn’t be solved in one surgery. Zucchelli insisted on the importance of soft tissue thickness to prevent future recessions. There was some doubt as to whether an average doctor could successfully perform Zucchelli’s technique to obtain the same results as him.

“Zucchelli insisted on the importance of soft tissue thickness to prevent future recessions”

A flapless procedure could also be a good option for the patient, and wouldn’t interfere with the crestal vascular supply. It may be the best choice (provided that the site has adequate bone and soft tissue dimensions). However, Zucchelli pointed out that by ‘going flapless’, the soft tissue thickness can’t be improved and, consequently, future recession cannot be prevented.

“A flapless procedure could also be a good option for the patient”

The second case was not considered a good candidate for immediate implant placement. Buser said he would prefer early placement (4–6 weeks), after soft tissue healing will have provided extra connective tissue to cover the GBR graft, and would simultaneously place the implant. Buser said that decisions would be made about additional soft tissue procedures at the re-evaluation stage (when uncovering the implant). Zucchelli said he would wait six months for total healing and would then perform the ‘soft tissue approach’ described in his presentation. Roccuzzo revealed that the method he chose was socket grafting for alevolar ridge preservation (ARP), in order to give himself a better opportunity to instruct the patient in oral hygiene. According to both speakers the problem with socket grafting in case of a missing buccal bone wall is that biomaterials are in contact with soft tissue and are not integrated with bone. For the past five years, Buser has used socket grafting much more frequently, in particular in elderly patients. This helps to reduce the morbidity for patients by using a flapless implant placement technique after four to six months, and eliminates the need for a bone augmentation procedure.

Buser uses socket preservation mainly in cases involving elderly patients with reduced mobility as a simpler approach with flapless surgery, using narrow diameter implants and without augmentation. Zucchelli only recommends this approach when primary stability cannot be obtained.

“Buser uses socket preservation mainly in cases involving elderly patients with reduced mobility”

In the third case, Buser’s preferred approach was resective: implantoplasty to eliminate the rough surface and re-adaptation of the flap (since there are no aesthetic concerns in this particular case). Zucchelli emphasised that something had to be done before mucositis set in, since the best time to treat dehiscence is before the rough surface is exposed and contaminated. In this case, he recommended his ‘soft tissue approach’ to prevent future problems.