The success of implant-supported dental prostheses is

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1 CASE LETTER Pouch Roll Technique for Implant Soft-Tissue Augmentation of Small Defects: Two Case Reports With 5-Year Follow-Up Jorge Saade, DDS, MD 1, PhD 1 Bruno Salles Sotto-Maior, DDS, MD, PhD 2 * Carlos Eduardo Francischone, DDS, MD, PhD 1 Marcelo Bassani, DDS, MD 1 André Navas Alves de Castro 1 Plinio Mendes Senna, DDS, MD 3, PhD 3 INTRODUCTION The success of implant-supported dental prostheses is well documented by prospective long-term studies, 1,2 demonstrating their reliability and versatility in solving esthetic and functional issues. 3,4 However, collapse of the alveolar ridge after tooth extraction is a common occurrence, limiting the bone available for implant placement. 5 Horizontal and vertical bone resorption is more extensive in the first year after tooth loss, with ridge volume reaching 60% reduction after 2 years. 6 Moreover, bone resorption can be exacerbated when the tooth is associated with inflammation or trauma or the patient has submitted to multiple extractions. 7,8 Thus, additional procedures may be needed to recover tissue loss and achieve satisfactory esthetic results. Despite surgical procedures such as alveolar ridge augmentation before or during implant insertion, 9,10 preoperative orthodontics (forced extrusion) 11,12 is recommended to augment preexisting bone defects. An early approach is recommended to minimize bone resorption and avoid the morbidity and complications of these procedures. However, even minimal bone resorption can lead to deficiencies in soft-tissue contour, which can be managed by soft-tissue augmentation during or after implant insertion. 5,13 Several tissue augmentation techniques are proposed to enhance esthetics in mild or moderate horizontal defects 5,13 ; however, the choice of therapy depends on the dimensions and position of the defect. These techniques include the subgingival connective tissue graft, 14 the roll technique or a connective tissue pedicle graft, 5,13 the full-thickness gingival onlay graft, 15 and combination onlay-interpositional grafts. 5 1 Department of Implantology, São Leopoldo Mandic Dental School, Campinas, São Paulo, Brazil. 2 Department of Restorative Dentistry, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil. 3 Department of Health Sciences Centre, Unigranrio, Rio de Janeiro, Rio de Janeiro, Brazil. * Corresponding author, bruno.sotto@ufjf.edu.br DOI: /AAID-JOI-D Other clinicians have either adapted or modified these techniques to accomplish localized ridge augmentation around dental implants during the first or second stage of surgery using a modified roll technique, 7 a rolled split palatal flap, 16 or a beveled palatal approach. 17 A modification of the original pouch roll technique can be used during the second surgery stage to augment marginal gingival thickness on the buccal side and provide esthetics to single or multiple dental implant rehabilitations. It is easy to perform, but it lacks long-term evidence of soft-tissue stability. Therefore, this article presents a pouch roll technique to provide buccal soft-tissue augmentation of small defects during placement of a nonsubmerged implant or during the second stage of a submerged implant, with 5- year follow-up. TECHNIQUE DESCRIPTION After administration of local anesthesia with 2% lidocaine plus epinephrine 1: , an intrasulcular buccal incision was made, which continued interproximally along the teeth to the palate, followed by a horizontal incision (Figures 1 and 2). Then a semilunar or circular incision was carried out, maintaining a buccal pedicle to preserve the delicate 1 to 2 mm of gingival sulcus adjacent to the teeth, which will become the interproximal papillae (Figure 3). Afterward, the minipedicle flap was deepithelialized using a 15C scalpel blade held firmly with atraumatic soft-tissue pliers. A fullthickness flap was elevated, creating a pouch the length of the minipedicle flap. It made the division of retail in the direction to proximal apical in the receptor, resulting in a pocket. After obtaining this pocket or framework, the portion wheel is circular or semilunar into the same tissue volume by increasing the buccal region (Figure 4). This provided a dualpurpose soft-tissue stratum on the buccal surface of the implant while preserving the integrity of the papilla during installation of the nonsubmerged implant. The tissue around the abutment or provisional prosthesis healed with an emergent profile suitable for holding the soft tissue in Journal of Oral Implantology 315

Pouch Roll Technique for Implant Soft-Tissue Augmentation FIGURES 1 3. FIGURE 1. Preoperative occlusal view 6 months after stage 1 implant surgery. FIGURE 2.

2 Pouch Roll Technique for Implant Soft-Tissue Augmentation FIGURES 1 3. FIGURE 1. Preoperative occlusal view 6 months after stage 1 implant surgery. FIGURE 2. Intrasulcular buccal incision accomplished and palatal horizontal incision. FIGURE 3. Buccal minipedicle flap. position. It is helpful to use a horizontal mattress suture to ensure intimate tissue contact of the folded trapdoor. The palatal incision was closed with 2 single interrupted sutures (Figures 5 and 6). For postsurgical pain control, 600 mg ibuprofen every 4 to 6 hours was prescribed, and 500 mg amoxicillin was prescribed 3 times daily for 7 days to prevent infection. The patient was instructed to avoid brushing and trauma to the surgical site and to rinse every 8 hours with 0.2% chlorhexidine gluconate (Figures 7 and 8). DISCUSSION Implant therapy in the anterior maxilla is a challenge for clinicians because they are often confronted with tissue deficiencies caused by various conditions and high esthetic demands by patients. 3 Thus, achieving and maintaining an adequate marginal gingival contour and sufficient width of keratinized tissue around the implant-supported prosthesis are important for the maintenance of peri-implant health and optimal esthetics. 5,13 This study demonstrated soft-tissue 316 Vol. XLI/No. Three/2015

Saade et al FIGURES 4 6. FIGURE 4. Deepithelializing the minipedicle flap using a 15C scalpel blade. FIGURE 5. Minipedicle flap rolled under the buccal pouch. FIGURE 6.

3 Saade et al FIGURES 4 6. FIGURE 4. Deepithelializing the minipedicle flap using a 15C scalpel blade. FIGURE 5. Minipedicle flap rolled under the buccal pouch. FIGURE 6. Immediate postoperative buccal view. stability at the 5-year follow-up of a pouch roll technique to restore the marginal gingival contour. Previous clinical studies have shown that the facial wall of extraction sockets in the anterior maxilla is often thin mainly comprised of bundle bone and is resorbed quickly (within 4 to 8 weeks), leading to a reduction in bone height of approximately 2 to 3 mm on the facial aspect regardless of whether an implant is placed in the socket. 6,7 Therefore, for optimal esthetic outcome, soft-tissue augmentation should be considered in implant-supported rehabilitation. The original pouch roll technique was first described by Abrams in in reconstructing the gingival margin contour around the residual edentulous ridge for a fixed prosthesis. Later, Scharf and Tarnow 19 and Hürzeler 20 suggested the use of this technique to reconstruct the gingival margin contour of a mild or moderate buccal deficiency during the second stage of implant surgery. However, it is recommended that this technique be performed concomitant to implant surgery, which provides the second-stage surgery an additional opportunity for peri- Journal of Oral Implantology 317

Pouch Roll Technique for Implant Soft-Tissue Augmentation FIGURE 7 AND 8. FIGURE 7. (a d) Buccal and occlusal views at 5-year follow-up, clinical aspect. FIGURE 8. Second case report.

4 Pouch Roll Technique for Implant Soft-Tissue Augmentation FIGURE 7 AND 8. FIGURE 7. (a d) Buccal and occlusal views at 5-year follow-up, clinical aspect. FIGURE 8. Second case report. (a) Preoperative aspect. (b) Minipedicle flap. (c) Minipedicle flap rolled under the buccal pouch. (d) Immediate postoperative buccal view. (e) Immediate postoperative occlusal view. (f) Five-year follow-up, clinical aspect. implant tissue management. Advantages of the modified pouch roll technique are preservation of the integrity of the papilla, increased soft-tissue thickness, improvement in esthetics by eliminating the buccal soft-tissue concavity, and obtaining healing by primary intention. 5,10,11,13,16 In cases of minimal bone volume, narrow implants and the modified pouch roll technique can be used as an alternative to bone grafts to minimize postoperative morbidity and risks of infection and to reduce cost and treatment time. However, restoration of more than 2 to 3 mm of soft tissue requires bone-grafting procedures. Accordingly, our case report has demonstrated that this procedure is considered more reproducible, more predictable, and less invasive for small defects. REFERENCES 1. Camargos GDV, do Prado CJ, das Neves FD, Sartori IA de M. Clinical outcomes of single dental implants with external connections: results after 2 to 13 years. Int J Oral Maxillofac Implants. 2012;27: Francetti L, Azzola F, Corbella S, Taschieri S, Del Fabbro M. Evaluation of clinical outcomes and bone loss around titanium implants with 318 Vol. XLI/No. Three/2015

5 Saade et al oxidized surface: six-year follow-up results from a prospective case series study. Clin Implant Dent Relat Res. 2014;16: Cordaro L, Torsello F, Chen S, Ganeles J, Brägger U, Hämmerle C. Implant-supported single tooth restoration in the aesthetic zone: transmucosal and submerged healing provide similar outcome when simultaneous bone augmentation is needed. Clin Oral Implants Res. 2013;24: Luo Z, Zeng R, Chen Z. Single implants in the aesthetic zone: analysis of recent peri-implant soft tissue alterations and patient satisfaction. A photographic study. Int J Oral Maxillofac Implants. 2011;26: Park S-H, Wang H-L. Pouch roll technique for implant soft tissue augmentation: a variation of the modified roll technique. Int J Periodont Restor Dent. 2012;32:e116 e Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L, Cardaropoli G. Socket preservation using bovine bone mineral and collagen membrane: a randomized controlled clinical trial with histologic analysis. Int J Periodont Restor Dent. 2012;32: Barone A, Ricci M, Tonelli P, Santini S, Covani U. Tissue changes of extraction sockets in humans: a comparison of spontaneous healing vs. ridge preservation with secondary soft tissue healing. Clin Oral Implants Res. 2013;24: Horváth A, Mardas N, Mezzomo LA, Needleman IG, Donos N. Alveolar ridge preservation: a systematic review. Clin Oral Investig. 2013;17: Nevins M, Camelo M, Nevins ML, Ho DK, Schupbach P, Kim DM. Growth factor-mediated combination therapy to treat large local human alveolar ridge defects. Int J Periodont Restor Dent. 2012;32: Steigmann M, Salama M, Wang H-L. Periosteal pocket flap for horizontal bone regeneration: a case series. Int J Periodont Restor Dent. 2012; 32: Lin C-D, Chang S-S, Liou C-S, Dong D-R, Fu E. Management of interdental papillae loss with forced eruption, immediate implantation, and root-form pontic. J Periodontol. 2006;77: Amato F, Mirabella AD, Macca U, Tarnow DP. Implant site development by orthodontic forced extraction: a preliminary study. Int J Oral Maxillofac Implants. 2012;27: Tinti C, Parma-Benfenati S. Minimally invasive technique for gingival augmentation around dental implants. Int J Periodont Restor Dent. 2012;32: Dogan N, Okcu KM, Ortakoglu K, Dalkiz M, Gunaydin Y. Barrier membrane and bone graft treatments of dehiscence-type defect at existing implant: a case report. Implant Dent. 2003;12: Lee Y-M, Kim D-Y, Kim JY, et al. Peri-implant soft tissue level secondary to a connective tissue graft in conjunction with immediate implant placement: a 2-year follow-up report of 11 consecutive cases. Int J Periodont Restor Dent. 2012;32: Nemcovsky CE, Artzi Z. Split palatal flap. I. A surgical approach for primary soft tissue healing in ridge augmentation procedures: technique and clinical results. Int J Periodont Restor Dent. 1999;19: Peñarrocha M, García-Mira B, Martinez O. Localized vertical maxillary ridge preservation using bone cores and a rotated palatal flap. Int J Oral Maxillofac Implants. 2005;20: Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Gen Dent. 1980;1: Scharf DR, Tarnow DP. Modified roll technique for localized alveolar ridge augmentation. Int J Periodont Restor Dent. 1992;12: Hürzeler MB, von Mohrenschildt S, Zuhr O. Stage-two implant surgery in the aesthetic zone: a new technique. Int J Periodont Restor Dent. 2010;30: Journal of Oral Implantology 319

Pouch Roll Technique for Implant Soft Tissue Augmentation: A Variation of the Modified Roll Technique

e116 Pouch Roll Technique for Implant Soft Tissue Augmentation: A Variation of the Modified Roll Technique Sang-Hoon Park, DDS, MS* Hom-Lay Wang, DDS, MSD, PhD** This paper presents three cases of peri-implant