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The Keyhole Access Expansion Technique for Flapless Implant Stage-Two Surgery: Technical Note

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In addition to osseointegration and restoration of function, patient satisfaction is a key element in the success of implant therapy. Especially in the esthetic zone, an essential part of the procedure aims at creating a definitive implant restoration that cannot be distinguished from the adjacent natural teeth. The present patient shows that, after localized ridge defects are reconstructed during implant surgery, a favorable esthetic and functional result can be achieved employing the keyhole access expansion technique for stage-two surgery, which is easy to perform, safe, and minimally invasive.
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The International Journal of Periodontics & Restorative Dentistry
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
The clinical replacement of lost natural
teeth by osseointegrated implants has
become a therapy with documented
success in the anterior maxilla.1In addi-
tion to osseointegration and restora-
tion of function, patient satisfaction is
a key element in the success of implant
therapy. Especially in the esthetic zone,
the procedure seeks to create a defin-
itive restoration that cannot be distin-
guished from the adjacent natural
teeth. To achieve perfect tissue condi-
tions, a variety of specific procedures
have been developed, including bone
augmentation protocols, connective
tissue grafting, and reconstruction of
lost papillae.2–4 All these techniques
aim to reconstruct the soft and hard tis-
sues of the alveolar ridge.
Various studies have proven the
reliability of bone grafting to recon-
struct the alveolar ridge with bioab-
sorbable membranes in guided bone
regeneration techniques.5Once an
implant is placed, there is usually no
need for the removal of synthetic
material during stage-two surgery.
Augmentation of the connective
tissue can be achieved via connective
tissue transplantation from the palate
if needed. These techniques have
The Keyhole Access Expansion
Technique for Flapless Implant
Stage-Two Surgery: Technical Note
Arndt Happe, DDS, Dr Med Dent*
Gerd Körner, DMD, Dr Med Dent**
Andreas Nolte*
In addition to osseointegration and restoration of function, patient satisfaction is a
key element in the success of implant therapy. Especially in the esthetic zone, an
essential part of the procedure aims at creating a definitive implant restoration
that cannot be distinguished from the adjacent natural teeth. The present patient
shows that, after localized ridge defects are reconstructed during implant surgery,
a favorable esthetic and functional result can be achieved employing the keyhole
access expansion technique for stage-two surgery, which is easy to perform, safe,
and minimally invasive.
(Int J Periodontics Restorative Dent 2010;30:97–101.)
*Private Practice, Münster, Germany.
**Private Practice, Bielefeld, Germany.
Correspondence to: Dr Arndt Happe, Schützenstrasse 2, 48143 Münster, Germany; fax:
+49-251-40271; email: a.happe@dr-happe.de.
97
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been reported for the reconstruction of
the ridge with or without implants
using free or pedicled grafts.6–9
Employing the described techniques,
it is possible to repair localized ridge
defects and create perfect conditions
prior to stage-two surgery in a staged
approach. This would mean that there
is no need for further soft tissue manip-
ulation during stage-two surgery,
unless it is done to create minimally
invasive access to the implant platform
for abutment connection. A flapless
surgical approach would avoid scars,
denudation of the peri-implant bone,
and thinning of the soft tissue and
would therefore prevent bone loss
caused by resorption,10 which is espe-
cially important in bone grafting pro-
cedures. Minimally invasive surgery
and microsurgical protocols have been
reported to allow better tissue healing
and minimize scars and trauma.11–14
The present technique was in-
spired by a technique described by
Bernhart et al.15 It represents a further
modification of their access, simplifying
their technique and combining it with
further tissue expansion via an individ-
ual healing abutment. The advantages
for this stage-two surgery after recon-
struction of the alveolar ridge are:
Access to implant platform for
abutment connection
Minimal exposure of peri-implant
bone
Minimal destruction of soft tissue
Minimal incisions for minimal scars
Minimal discomfort for patient
Ease of performance
Method and materials
After local anesthesia is achieved with
4% articaine and 1:100,000 epineph-
rine (Ultracain forte, Aventis Pharma),
approximately 1 mm2of soft tissue on
top of the implant head is removed
with a no. 15 or smaller blade (Swann
Norton). The size of the hole is in-
creased by slowly but firmly pushing
and stretching the soft tissue with a
microraspatory (Papillenelevator micro
005, Mamadent). After approximately
5 minutes, the access hole should be
large enough for the cover screw to be
removed and the healing abutment to
be placed. Placement of the healing
abutment may result in ischemia of the
expanded peri-implant soft tissue
because of the pressure created by its
size. After the initial healing of the soft
tissue has taken place, an individual
healing abutment or an abutment of
greater diameter may be placed for
further soft tissue expansion and con-
ditioning.
Case presentation
A 23-year-old man presented for a
single-tooth implant restoration of the
maxillary left central incisor (Fig 1).
After implant placement and recon-
struction of the localized ridge defect
using a connective tissue graft (Fig 2),
stage-two surgery was performed with
the described method (Fig 3). After
the healing abutment was placed,
ischemia was apparent, because the
diameter of the abutment was bigger
than the access hole (Fig 4). Two weeks
later, after initial healing of the soft tis-
sue was complete (Fig 5), an individual
98
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healing abutment (Fig 6) was placed to
apply further pressure on the soft tis-
sue to improve the esthetic result at
the soft tissue interface—especially
the papillae—and to refine the final
emergence profile before definitive
prosthetic restoration (Figs 7 and 8).
For the definitive restoration, which
was placed 8 weeks after stage-two
surgery, a custom-made zirconia abut-
ment was placed (Figs 9 and 10) and
an all-ceramic crown was cemented
(Fig 11).
Discussion
After correct implant placement and
reconstruction of the alveolar ridge
with resorbable membranes, the only
aim of stage-two surgery should be
the minimally invasive reopening of
the tissue to provide access to the
implant platform without denuding the
peri-implant bone or creating scars,
with minimal damage to the soft tissue,
and with minimal discomfort for the
patient.
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Volume 30, Number 1, 2010
Fig 1 (left)
Single-tooth gap with localized
ridge defect.
Fig 2 (right)
Situation after reconstruction
of tissues and implant placement. The black
dotted line indicates the size of the implant
platform, and the white dotted line indi-
cates the size of the surgical “keyhole”
access.
Fig 3 (left)
Minimally invasive stage-two
surgery is performed using tissue expan-
sion.
Fig 4 (right)
The healing abutment is
placed, resulting in ischemia at the site.
Fig 5 (left)
Site at 1 week after stage-two
surgery.
Fig 6 (right)
A customized healing abut-
ment is placed to apply further pressure,
again resulting in ischemia.
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During childhood, the anterior
teeth erupt slowly, with only a tip of the
incisor edge emerging initially. During
the emergence process, the soft tissue
is expanded and conditioned until the
typical gingival anatomy, including
papillae, the alveolar ridge, and gingi-
val scalloping, is created. The des-
cribed technique tries to copy and
accelerate this natural emergence
process during stage-two surgery in
implant therapy via expanding the
supraimplant soft tissue. Therefore,
access is minimally invasive, and the
soft tissue is conditioned by applying
mechanical forces.
The present patient shows that,
after localized ridge defects are recon-
structed during implant surgery, it is
possible to achieve a favorable esthetic
and functional result by using the easy,
safe, and minimally invasive so-called
keyhole access expansion technique
during stage-two surgery.
100
The International Journal of Periodontics & Restorative Dentistry
Fig 7 (left)
Site 1 week after placement of
the customized healing abutment.
Fig 8 (right)
Soft tissue conditions at the
time of definitive restoration.
Fig 9 (left)
Customized zirconia abutment.
Fig 10 (right)
Periapical radiograph of the
customized zirconia abutment and implant.
Fig 11 (left)
Definitive restoration
(cemented all-ceramic single crown).
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Along with osseointegration and restoration of function, the patient's subjective satisfaction with the esthetic result is a touchstone of the success of implant therapy. Although esthetic restoration of natural teeth can be achieved routinely through appropriate tooth preparation and a natural-looking design on the part of the dental laboratory, the road to success is much more complicated with implants, because of atrophy of bone and mucosa. Surgical techniques, paths of incision, and useful instruments for implant therapy are described, from implant placement to exposure. These methods help to provide durable, functional, and esthetic results.
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Objectives: Application of the guided tissue regeneration (GTR) principle and utilization of enamel matrix derivative (EMD) have both been shown to result in periodontal regeneration. While clinical investigations have demonstrated that the use of a microsurgical concept in combination with the GTR technique positively affects the percentage of primary closure and the amount of tissue preservation, no such information is available for EMD-treated periodontal defects. It was the aim of the present investigation to assess the clinical effect of the microsurgical access flap and EMD treatment with an emphasis on the evaluation of early wound healing. Material and methods: Eleven patients displaying at least one pair of intrabony periodontal defects with an intrabony component of > or =3 mm participated in the study. At baseline and at 6 and 12 months after surgery, the following clinical parameters were assessed by a blinded examiner: oral hygiene status (API), gingival inflammation (BOP), probing pocket depth (PPD), clinical attachment level (CAL) and gingival recession (GR). Defects were randomly assigned to test or control treatment, which both consisted of a microsurgical access flap procedure designed for maximum tissue preservation. The exposed root surfaces of the test sites were conditioned with a 24% EDTA gel followed by EMD (Emdogain(R)) application. Primary flap closure was achieved by a 2-layered suturing technique. Postoperative healing was evaluated by a newly introduced early wound-healing index (EHI) at 1 and 2 weeks after surgery. Results: Both test and control treatment resulted in a statistically significant mean CAL gain of 2.8 and 2.0 mm at 6 months, and 3.6 and 1.7 mm at 12 months, respectively (p<0.05). Differences in CAL gain between the two treatment modalities were statistically significant at both time points (p<0.05). Additional GR values after 12 months averaged 0.3 and 0.4 mm for test and control sites, respectively, and did not reach statistical significance (p> or =0.05). Two weeks after surgery, primary closure was maintained in 89% of the test sites and in 96% of the control sites. Conclusion: Both treatment modalities using the microsurgical flap procedure resulted in a high percentage of primary flap closure and maximum tissue preservation. In terms of PPD reduction and CAL gain, the combination with EMD application appeared to be superior to the microsurgical access flap alone.