Soft Tissue Punch Technique for Aesthetic Implant Dentistry
Thomas J. Salinas, DDS
Implant therapy has revolutionized dentistry, furnishing clinicians with aesthetic, predictable means of replacing missing teeth. Several contemporary implant systems are capable of providing options for developing aesthetic implant restorations. These options are based upon sound implant placement and meticulous soft tissue management. The requisites for the placement of single-tooth implant restorations have been well established by Sullivan and Parel. Salama, Garber, Tarnow, and numerous other clinicians have focused on soft tissue management. Secondary and even tertiary procedures have been advocated to obtain the maximum tissue volume required to make these restorations "emerge" from the soft tissues and appear lifelike.
Provided the proximal papilla can be preserved at the time of implant placement by excluding it from the flap, uncovering the implant can be accomplished in two ways. The same flap design can be used to uncover the implant, or a soft tissue punch can be utilized to minimize reflection of tissue. Historically, the punch was suggested and then critiqued for removing excessive amounts of precious keratinized tissue. Nevertheless, soft tissue punches have demonstrated promise as a means of preserving the soft tissue architecture, shortening treatment time, and minimizing scarring of the peri-implant tissues.
In order to utilize the punch procedure properly, the implant should be surgically indexed. As described by Spear, a positional locator can be fabricated to accomplish this procedure with precision.1 This will reliably provide a circular exposure over the head of the implant to allow the clinician to remove the cover screw and place the healing or prepared provisional abutment. The punch is actually inserted from a slight lingual angle to expand and provide a small amount of excess tissue to the facial aspect. Healing is generally more predictable and shorter than that following split-thickness dissection with flap advancement.2
Gradual expansion of the soft tissues can be performed with anatomic abutments either at uncovering or at a subsequent treatment stage. It is imperative to perform this procedure with an abutment and provisional restoration to form and properly transfer the gingival margin to the master cast. This expansion ensures that the restorative dimensions are increased below the gingival tissues to provide for proper emergence and create contours that are both aesthetic and conducive to hygiene procedures.
Single-stage implant placement has gained popularity, as predictable soft tissue profiles may be obtained with primary implant stability. This appears to be prevalent with mandibular implants or areas where bone grafting is not necessary. In the maxilla or areas to be grafted, however, second- and third-stage procedures may be required. In these circumstances, uncovering may involve flap reflection for membrane retrieval and other secondary or tertiary procedures aimed at achieving a more harmonious soft tissue profile. Soft tissue punch uncovering, therefore, is primarily indicated for cases that have adequate keratinized, fixed soft tissues and intact papillae to achieve optimal soft tissue architecture for single- and multitooth implant restorations.
*Assistant Professor, Department of Prosthodontics, Louisiana State University School of Dentistry, New Orleans, Louisiana.
- Spear F. Soft tissue management of osseointegrated dental implants: Presentation to the American Academy of Fixed Prosthodontics. Chicago, IL: 1998.
- Block MS. Soft tissue procedures related to dental implants. J Oral Maxillofac Surg 1998. In press.