The effects of tissue punch diameter on healing around implants in flapless implant surgery

Du-Hyeong Lee; Seung-Mi Jeong; Byung-Ho Choi

doi:10.4047/jkap.2009.47.3.301

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Lee, Jeong, and Choi: The effects of tissue punch diameter on healing around implants in flapless implant surgery

ORIGINAL ARTICLE

J Korean Acad Prosthodont 2009;47(3):301-311.

Published online: 18 December 2009

DOI: https://doi.org/10.4047/jkap.2009.47.3.301

The effects of tissue punch diameter on healing around implants in flapless implant surgery

Du-Hyeong Lee, DDS¹, Seung-Mi Jeong, DDS, PhD^2,^∗, Byung-Ho Choi, DDS, PhD³

^¹Graduate student, Department of Prosthodontics, Wonju Christion Hospital, Yonsei University, Wonju, South Korea

^²Associate professor, Department of Prosthodontics, Wonju Christion Hospital, Yonsei University, Wonju, South Korea

^³Professor, Department of Oral & Maxillofacial Surgery, College of Dentistry, Yonsei University, Seoul, South Korea

Corresponding Author: Seung-Mi Jeong Department of Prosthodontic Dentistry, Yonsei University, Wonju College of Medicine, 162 Ilsan-dong, Wonju, 220-701, South Korea +82 33 741 1443: e-mail, smj3@yonsei.ac.kr

Received 18 June 200926 June 2009 Accepted 29 June 2009

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Statement of problem

Flapless implant surgery using a soft tissue punch device requires a circumferential excision of the mucosa at the implant site. To date, Although there have been several reports on clinical outcomes of flapless implant surgeries, there are no published reports that address the appropriate size of the soft tissue punch for peri-implant tissue healing.

Purpose

In an attempt to help produce guidelines for the use of soft tissue punches, this animal study was undertaken to examine the effect of soft tissue punch size on the healing of peri-implant tissue in a canine mandible model.

Material and methods

Bilateral, edentulated, flat alveolar ridges were created in the mandibles of six mongrel dogs. After a three month healing period, three fixtures (diameter, 4.0 mm) were placed on each side of the mandible using 3 mm, 4 mm, or 5 mm soft tissue punches. During subsequent healing periods, the peri-implant mucosa was evaluated using clinical, radiological, and histometric parameters, which included Gingival Index, bleeding on probing, probing pocket depth, marginal bone loss, and vertical dimension measurements of the peri-implant tissues.

Results

The results showed significant differences (P < 0.05) between the 3 mm, 4 mm and 5 mm tissue punch groups for the length of the junctional epithelium, probing depth, and marginal bone loss during healing periods after implant placement. When the mucosa was punched with a 3 mm tissue punch, the length of the junctional epithelium was shorter, the probing depth was shallower, and less crestal bone loss occurred than when using a tissue punch with a diameter ≥ 4 mm.

Conclusion

Within the limit of this study, the size of the soft tissue punch plays an important role in achieving optimal healing. Our findings support the use of tissue punch that 1 mm smaller than implant itself to obtain better peri-implant tissue healing around flapless implants. (J Korean Acad Prosthodont 2009;47:301-11)

Keywords: dental implant, flapless, tissue punch, peri-implant tissue

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Fig. 1.

Soft tissue punches 3 mm, 4 mm and 5 mm in diameter.

Fig. 2.

Clinical photograph of a drill that has only 0.5 mm cutting edge at terminal portion and a blunted edge at other portion (A) and diagram of cross section (B).

Fig. 3.

Clinical feature immediately after punching using 3 mm, 4 mm and 5 mm tissue punches.

Fig. 4.

Clinical feature after placing a 4 mm fixture and a 4.5 mm permucosal healing abutment.

Fig. 5.

Diagram for classifying morphology of marginal gingiva.

Fig. 6.

Measurement of level of the marginal gingiva at buccal side of the abutment.

Fig. 7.

Clinical feature of measuring pocket depths using probes with a probing force of 0.2 N.

Fig. 8.

Diagram for histometric analysis.

Fig. 9.

Graph of change of the marginal gingiva morphology.

Fig. 10.

Graph of change of the soft tissue level.

Fig. 11.

Graph of change of gingival index.

Fig. 12.

Clinical photograph of the implants at 3 weeks (A) and 12 weeks (B) after implant placement.

Fig. 13.

Graph of change of the crestal bone loss.

Fig. 14.

Periapical radiographs taken at 3 weeks (A) and 12 weeks (B) after implant placement. Note that most early bone loss occurred around the implants during the first three weeks after implant placement, and more marginal bone loss occurred with the ≥ 4 mm tissue punch than with the 3 mm tissue punch.

Fig. 15.

Magnified view of the specimens showing the peri-implant mucosa. (A) Implant placed with a 3 mm tissue punch. (B) Implant placed with a 4 mm tissue punch. (C) Implant placed with a 5 mm tissue punch. (Toluidine blue stain, × 12)

Table I.

Marginal gingiva morphology

	3 mm group	4 mm group	5 mm group	P-values
0 week	3.0 ± 0.0	2.3 ± 0.5	1.0 ± 0.0	<.05
0.5 week	2.3 ± 0.5	2.2 ± 0.4	1.5 ± 0.5	<.05
1 week	2.2 ± 0.4	2.0 ± 0.3	1.7 ± 0.5	<.05
2 weeks	2.0 ± 0.0	2.0 ± 0.0	2.0 ± 0.0	>.05
3 weeks	2.0 ± 0.0	2.0 ± 0.0	2.0 ± 0.0	>.05
6 weeks	2.0 ± 0.0	2.0 ± 0.0	2.0 ± 0.0	>.05
12 weeks	2.0 ± 0.0	2.0 ± 0.0	2.0 ± 0.0	>.05

Table II.

Soft tissue level : Buccal

	3 mm group	4 mm group	5 mm group	P-values
0 week	0.0 ± 0.0	0.0 ± 0.0	0.0 ± 0.0	>.05
0.5 week	0.4 ± 0.1	0.4 ± 0.2	0.6 ± 0.2	>.05
1 week	0.5 ± 0.1	0.8 ± 0.2	0.9 ± 0.2	<.05
2 weeks	0.4 ± 0.1	0.9 ± 0.3	1.1 ± 0.4	<.05
3 weeks	0.2 ± 0.1	0.4 ± 0.2	0.5 ± 0.2	<.05
6 weeks	0.1 ± 0.1	0.2 ± 0.2	0.2 ± 0.4	>.05
12 weeks	0.0 ± 0.2	-0.3 ± 0.2	-0.5 ± 0.7	>.05

Table III.

Clinical and radiological parameters

	3 mm group	4 mm group	5 mm group	P-values
Probing depth (mm)
3 weeks	1.6 ± 0.5	1.9 ± 0.7	2.2 ± 0.5	<.05
6 weeks	1.5 ± 0.7	1.8 ± 0.4	2.0 ± 0.6	<.05
12 weeks	1.2 ± 0.6	1.6 ± 0.7	1.8 ± 0.6	<.05
Gingival index
0 week	0.0 ± 0.0	0.0 ± 0.0	0.0 ± 0.0	>.05
0.5 week	0.2 ± 0.4	0.7 ± 0.5	1.3 ± 0.9	<.05
1 week	0.1 ± 0.3	0.6 ± 0.5	0.9 ± 0.8	<.05
2 weeks	0.0 ± 0.0	0.5 ± 0.5	0.8 ± 0.4	<.05
3 weeks	0.0 ± 0.0	0.2 ± 0.7	0.5 ± 0.5	<.05
6 weeks	0.0 ± 0.0	0.0 ± 0.0	0.4 ± 0.5	>.05
12 weeks	0.0 ± 0.0	0.0 ± 0.0	0.2 ± 0.5	>.05
Bleeding on probing (BOP)
3 weeks	0.3 ± 0.5	0.4 ± 0.5	0.9 ± 0.7	>.05
6 weeks	0.1 ± 0.3	0.1 ± 0.3	0.6 ± 0.7	<.05
12 weeks	0.1 ± 0.3	0.2 ± 0.4	0.3 ± 0.5	>.05
Crestal bone loss
0 week	0.0 ± 0.0	0.0 ± 0.0	0.0 ± 0.0	>.05
1 week	0.0 ± 0.1	0.1 ± 0.1	0.2 ± 0.1	<.05
2 weeks	0.2 ± 0.1	0.3 ± 0.2	0.4 ± 0.2	<.05
3 weeks	0.2 ± 0.1	0.5 ± 0.3	0.6 ± 0.3	<.05
6 weeks	0.3 ± 0.1	0.6 ± 0.4	0.7 ± 0.6	<.05
12 weeks	0.3 ± 0.1	0.6 ± 0.5	0.7 ± 0.5	<.05

Table IV.

Histometric parameters

3 mm group	4 mm group	5 mm group	P-values
PM-aJE (mm) 1.2 ± 0.3	1.5 ± 0.6	1.7 ± 0.5	<.05
aJE-B (mm) 1.0 ± 0.2	1.1 ± 0.3	1.2 ± 0.3	>.05

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