Importance of existence of keratinized gingival on the health of tissue around over dentures supporting implants: a case report

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1 Importance of existence of keratinized gingival on the health of tissue around over dentures supporting implants: a case report Maliheh Hamedi Jahroumi 1, Majid Vatankhah 2, Maryam Voosooghi shashkolati 3, Parviz Amini 4 1 Assistant Dental & Facial Prosthodontics, Faculty of Dentistry, Kerman University of Medical Sciences, Iran 2 Faculty of Hormozgan University of Medical Sciences and Anesthetist, Intensive Care and Pain Control Research Center Bandar Abbas, Iran (Corresponding Author) 3 Assistant Dental & Facial Prosthodontics, Faculty of Dentistry, Kerman University of Medical Sciences, Iran 4 Dental & Facial Prosthodontics, Faculty of Dentistry, Kerman University of Medical Sciences, Iran Abstract Over denture supported by denture implants is a successful treatment choice with a high forecasting ability in toothless people In this case, temporary abutments were used to form gingival due to patient s reluctance to undergo further surgery. Although this method bears less pain and discomfort compared to surgery, but it burdens the patient with extra cost of acquiring temporary abutments. No problem was observed in this case after 12 months. In any case, further follow ups and studies for definite conclusions are required. Keywords: keratinized gingival, dentures implants, tissue health Introduction Recently, with changes in surface specifications, the osteointegration implant has become less controversial (3). Stability and health of the tissue around implants is vital for the long term success of dental implants (4). Around teeth and dental implants there is phlegm or gingival through which they enter oral cavity. In the cervical of these structures sulcular epithelium connects to junctional epithelium (5). Junctional epithelium is 1mm long which connects to teeth and dental implants via hemidesmosome (6). There are 1mm long connective tissues under junctional epithelium. Teeth in this layer contain fibers which enter cementum layer vertically. Connective tissues around implants are parallel or oblique and do not enter the surface of the implant (7). In addition, blood supply around implant is less than teeth because there is no periodontal ligament around implant (8). Due to anatomic differences, reactions of periodontal tissue and Perry implant to bacterial infections may be different (9-10). Ericson et al. reported that after discontinuation of health in dog spreading apical, inflammation in Perry implant phlegm was larger and more bone erosion was observed around implants than around teeth (9). This indicates that Perry implant phlegm is more disposed to destruction than tissues around teeth (10). In Mr. Strub et al. study on dog model, no difference in gingival erosion and bones in places with or without keratinized gingival was reported (11). Existence of keratinized tissue with a 2mm width for creating torrent of soft tissue around natural teeth is clinically desirable (12), although the necessity of existence of keratinized tissue around dental implants is still being discussed (13-14). The role of plaque in etiology of Perry implant tissue illnesses has been found (15-16). Some authors have claimed that keratinized tissue will remain healthy with appropriate plaque control around implant, even with minimum presence (13-14). It was reported that patient dissatisfaction has been related to over denture supported by implant with insufficient keratinized tissue around implant (17). It was also reported that mechanical irritation of tissues occurs due to non-keratinized tissue movement under function (17-18). Adibard stated when supporting implants of over denture have less than 2mm gap with keratinized gingival, more aggregation of plaque, inflammation of gingival, bleeding during propping and phlegm erosion will occur. They also showed over denture flange leads to accumulation of plaque and phlegm inflammation (19). Contrariwise, Hekman et al. stated that there is a significant difference between bleeding index in places with or without presence of keratinized gingival under over denture (20). By the same token, Kaptine showed that there is no difference in depth of probe and plaque and/or bleeding around implant with or without keratinized gingival 21 67

2 Case Report The patient is a 65-year-old woman who was referred to the Kerman Prosthetics Dental School for edentulous maxilla and mandible prosthetic reconstruction ridge. The main complaint of the patient was difficulty in chewing and lack of engaging of lower denture. She had used dentures for 10 years and her teeth had fallen out 11 years previous due to decay. The patient had no particular medical background and was not under medical treatment. Facial examination revealed a decrease of facial height. This case became clear with clinical examination of the patient without prosthesis when her chin and nose were closer together. Other findings included indented cheek, lips without support, slight distortion of pronunciation of sibilant. General condition of the patient was normal. Intraoral examination showed maxillary and mandible u-shape arch. The patient lacked keratinized gingival in anterior mandible. OPG and CBCT radiography of mandible was requested for the patient. Diagnosis was done on the basis of OPG and CBCT and included Full mandible and maxillary edentulous and bone type D2 with the height of 15mm in anterior mandible. The proposed treatment plan for the patient was full denture maxillary and mandibular over denture. The treatment plan was confirmed after receiving informed consent of the patient. Location of implant was selected on the basis of existing bone and was divided into 5 zones A, B, C, D & E, and was divided according to St Louis (1999) classification beginning from right side. Acrylic denture was used to build the surgical stent. 3 implants with the lengths of 10mm and 4.5mm (noble biocare) were selected. Specified places for the implants were A, C & E. The patient was transferred to the pre-surgery ward. 1. Inferior Alveolar anesthesia was used. Crestal incision together with vertical incision was used to expose the point of surgery. Firstly, the Pilot drill was used and then a series of end cutting drills for gradual increase of diameter of point of osteotomy was employed. Parallel of implants was checked using parallel gauge. Point of osteotomy was washed using saline and the fixtures were put in place. Cover screw was placed on the implants and the flap was closed using continuous stitches and covered the fixtures completely. 2. Stitches were removed a week later and several visits arranged for the next 3 months. 3. Three months after placing of implants, location of implants was clarified by probe and cover screw was replaced by healing screw. The patient was visited 1 week later. 4. Six months later alloderm graft was used to enhance keratinized tissue. Graft disappeared after 3 months and the patient was grafted a second time and it failed the second time too. 5. Patient lacking keratinized gingival around implant was referred to prosthesis section. 3 temporary abutments were used due to super elevation of gingival for 1 month to allow formation of gingival. 6. The initial mould was taken by alginate and compound. Mould was cast by stone. 2 layers of wax were placed in the healing area and a separate tray was constructed. 7. Casting was achieved by open tray method. Border mould was done by green compound. Secondary casting was achieved using polyether medium body (impergum). Casting was done using compound, transfer copings were connected using acrylic. The acrylics were then separated by ferz. A new tray was made on the cast. 8. Coping impressions were transferred to the mouth and were reconnected using acrylic and border mould was done by green compound and the third casting was done by polyether and casting was done using stone. 9. Base of records was built on cassettes and CR connection was recorded by green compound. Cassettes were mounted, teeth were clipped. 10. Teeth were tested inside the mouth. The necessary adjustments were carried out and then were cooked using acryl heat cure. 11. The milled bar was connected to the casting abutments that was made of cr-co alloy. Two wings were placed on the bar between the fixtures. 12. The patient was visited 24 and 48 hours later and adjustments were carried out. 13. The patient was given appropriate instructions in the care of implant and prosthesis. 14. The patient was visited 6 and 12 months later. There was no sign of inflammation or illness and patient was satisfied with the treatment. 68

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Discussion A comprehensive review of articles raises the ambiguous question as to whether keratinized gingival is vital for the health of tissue around implants.

In addition, articles relating to implants breakages do not clarify the amount of keratinized gingival needed for maintaining the health of the tissue.

4 Discussion A comprehensive review of articles raises the ambiguous question as to whether keratinized gingival is vital for the health of tissue around implants. Studies have shown contradictions in this respect which obstruct a definite conclusion. In addition, articles relating to implants breakages do not clarify the amount of keratinized gingival needed for maintaining the health of the tissue. It generally seems that existence of keratinized gingival is useful in some places and is unnecessary in other places. And this may differ in individuals and various parts of mouth. Particular conditions around implant such as (gingival chap, gingival erosion, shallow vestibule, elongation of frenum) may benefit from gingival graft which has not been reviewed enough. Instead, studies have often used control group and test as sufficient keratinized gingival and lack of keratinized gingival. In general, the margin of sub-gingival crown on natural teeth hosts the basis for aggregation of plaque and gingival inflammation ( ). It is assumed that inflammatory reactions around implant restorations are more severe than natural teeth because pre implant tissue is more susceptible to inflammation due to replacement of connective tissue by epithelium (9-7-25). In any case, this presumption is based on animal studies which evaluate tissues around implant when hygiene is stopped. These artificially created conditions create a weak theoretical basis and this information cannot be directly used for the purpose of treating patients. It is worth mentioning that the necessary individual plaque threshold for beginning of symptoms varies in people (26). The researchers have also mentioned that tissue reaction to plaque around implant is similar in patients (27-28). And, tissue reaction around implant, even when there is shortage of keratinized gingival, is not problematic ( ). Based on this study and RCTs related to plaque level and amount of keratinized gingival, we cannot conclude that all patients are more susceptible to plaque aggregation. Some studies have presented findings about increase of inflammation and gingival and bone erosion with reduction of keratinized gingival. An important explanation for the existing repugnance in studies is that health of soft tissue around implant can be maintained through good oral health even in the absence of keratinized gingival. Yeung suggests that increase of keratinized tissue around implant facilitates plaque control with reduction of mucous tissue motion (31). Esposito et al. concluded during a systematic review that there is insufficient evidence for increase of keratinized gingival for establishing tissue health around implant (32). Reference 1-Jemt T, Chai J, Harnett J, et al. A five-year prospective multicenter follow-up report on overdentures supported by osseointegrated implants. Int J Oral Maxillofac Implants. 1996;11: Meijer HA, Batenburg HK, Raghoebar GM, Vissink A. Mandibular overdentures supported by two Branemark, IMZ or ITI implants: a 5-year prospective study. J Clin Periodontol. 2004;31: Meijer HJA, Geertman ME, Raghoebar GM, Kwakman JM. Implant retained mandibular overdentures: 6-year results of a multicenter clinical trial on 3 different implant systems. J Oral Maxillofac Surg. 2001;59:

5 4-Batenburg RHK, Meijer HJA, Raghoebar GM, Vissink A. Treatment concept for mandibular overdentures supported by endosseous implants. A literature review. Int J Oral Maxillofac Implants. 1998;13: Wennström JL, Bengazi F, Lekholm U. The influence of the masticatory mucosa on the peri-implant soft tissue condition. Clin Oral Implants Res. 1994;5(1): Shimono M, Ishikawa T, Enokiya Y, et al. Biological characteristics of the junctional epithelium. J Electron Microsc (Tokyo). 2003;52(6): Berglundh T, Lindhe J, Ericsson I, et al. The soft tissue barrier at implants and teeth. Clin Oral Implants Res. 1991;2(2): Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of the vascular systems in the periodontal and periimplant tissues in the dog. J Clin Periodontol. 1994;21(3): Ericsson I, Berglundh T, Marinello C, et al. Long-standing plaque and gingivitis at implants and teeth in the dog. Clin Oral Implants Res. 1992;3(3): Lindhe J, Berglundh T, Ericsson I, et al. Experimental breakdown of peri-implant and periodontal tissues. A study in the beagle dog. Clin Oral Implants Res. 1992;3(1): Strub JR, Gaberthuel TW, Grunder U. The role of attached gingiva in the health of peri-implant tissue in dogs. 1. Clinical findings. Int J Periodontics Restorative Dent. 1991;11(4): Mericske-Stern R, Steinlin Schaffner T, Marti P, Geering AH. Peri-implant mucosal aspects of ITI implants supporting overdentures. A five-year longitudinal study. Clin Oral Implants Res. 1994;5: Sadowsky SJ. Treatment considerations for maxillary implant overdentures: a systematic review. J Prosthet Dent. 2007;97: Lang NP, Loe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol. 1972;43: Wennstrom J. Lack of association between width of attached gingiva and evelopment of soft tissue recession. A 5- year longitudinal study. J Clin Periodontol. 1987;14: Dorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of free autogenous gingival grafts: a four-year report. J Periodontol. 1982;53: Gould TR, Westbury L, Brunette DM. Ultrastructural study of the attachment of human gingiva to titanium in vivo. J Prosthet Dent. 1984;52: Abrahamsson I, Berglundh T, Wennstrom J, Lindhe J. The periimplant hard and soft tissues at different implant systems. A comparative study in the dog. Clin Oral Implants Res. 1996;7: Adibrad M, Shahabuei M, Sahabi M. Significance of the width of keratinized mucosa on the health status of the supporting tissue around implants supporting overdentures. J Oral Implantol. 2009;35(5): Heckmann SM, Schrott A, Graef F, et al. Mandibular two-implant telescopic overdentures. Clin Oral Implants Res. 2004;15(5): Kaptein ML, De Lange GL, Blijdorp PA. Peri-implant tissue health in reconstructed atrophic maxillae report of 88 patients and 470 implants. J Oral Rehabil 1999;26(6): Stetler KJ, Bissada NF. Significance of the width of keratinized gingiva on the periodontal status of teeth with submarginal restorations. J Periodontol. 1987;58(10): Lang NP, Kiel RA, Anderhalden K. Clinical and microbiological effects of subgingival restorations with overhanging or clinically perfect margins. J Clin Periodontol. 1983;10(6): Marcum JS. The effect of crown marginal depth upon gingival tissue. J Prosthet Dent. 1967;17(5): Lindhe J, Echeverria J. Consensus report of session II. In: Lang NP, Karring T, eds. Proceedings of the 1st European Workshop on Periodontology. Berlin, Germany: Quintessence Publishing; 1994: Cobb CM. Clinical significance of non-surgical periodontal therapy: an evidence-based perspective of scaling and root planing. J Clin Periodontol. 2002;29(suppl 2): Zitzmann NU, Berglundh T, Marinello CP, Lindhe J. Experimental peri-implant mucositis in man. J Clin Periodontol. 2001;28(6): Pontoriero R, Tonelli MP, Carnevale G, et al. Experimentally induced peri-implant mucositis. A clinical study in humans. Clin Oral Implants Res. 1994;5(4): Kim BS, Kim YK, Yun PY, et al. Evaluation of peri-implant tissue response according to the presence of keratinized mucosa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107(3):e24-e Brägger U, Bürgin WB, Hämmerle CH, Lang NP. Associations between clinical parameters assessed around implants and teeth. Clin Oral Implants Res. 1997;8(5): Yeung SC. Biological basis for soft tissue management in implant dentistry. Aust Dent J. 2008;53(suppl 1):S39-S Esposito M, Grusovin MG, Maghaireh H, et al. Interventions for replacing missing teeth: management of soft tissues for dental implants. Cochrane Database Syst Rev. 2007;18;(3):CD

Evaluation of peri-implant tissue response according to the presence of keratinized mucosa Abstract Purpose: Materials and methods Results:

Evaluation of peri-implant tissue response according to the presence of keratinized mucosa Bum-Soo Kim 1, Young-Kyun Kim 1, Pil-Young Yun 1, Yang-Jin Lee 2, Hyo-Jeong Lee 3, Su-Gwan Kim 4 1Department of