The dome technique: a new surgical technique to enhance soft-tissue margins and emergence profiles around implants placed in the esthetic zone

Tassos Irinakis, Salwa Aldahlawi, Tassos Irinakis, Salwa Aldahlawi

Abstract

Achieving symmetry of the soft-tissue margins between anterior maxillary dental-implant restorations and adjacent teeth is a therapeutic challenge for both the implant surgeon and the restorative dentist. This article describes a modified procedure utilizing autogenous connective-tissue grafts to improve primarily buccal soft-tissue margins and secondarily inter-proximal tissues around tooth-bound single dental implants. This technique has the advantage of allowing for coronal augmentation of the peri-implant soft tissue while maximizing the blood supply to the area by using tunneling-technique principles. A detailed description of the technique and a case with a stable result over 24 months after crown placement is presented.

Keywords: autogenous connective-tissue grafts; dental implants; esthetic dental treatment; peri-implant soft tissue; soft tissue augmentation; tunnel technique.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Surgical steps of Dome technique. Notes: (A, B) Having a healing abutment for 6–8 weeks is a prerequisite for the dome technique. The healing abutment helps to shape the peri-implant tissue. (C, D) When the healing abutment is removed, a space is created for the dome connective-tissue graft. (E) Partial-thickness blunt dissection is carried out all around the implant on the buccal, palatal, and interdental areas with a bent periosteal elevator that is used as a tunneling instrument. (F) The dotted line represents the circumferential incision line, and the arrows show the extent/spread of the tunnel preparation in all directions. (G, H) A connective-tissue graft is harvested from the contralateral side of the palate to allow for harvesting of the largest possible graft. (I, J) The CTG is carried to the “dome” pouch over the implant and inserted carefully in the buccal–palatal direction. It is then stabilized first along the buccal aspect by “blind” suture that penetrates the overlying buccal tissue and the underlying CTG. (K, L) The rest of the connective tissue is passed over the implant head and inserted into the palatal aspect and then “spread” laterally underneath the interdental papilla and sutured in place. Abbreviation: CTG, connective-tissue graft.
Figure 2
Figure 2
Uncovering the implant after healing of the dome connective tissue. Notes: (A) A semilunar incision is created over the estimated implant site. (B) A punch-biopsy instrument is used to demarcate the initial incision. (C) Only the palatal half of the tissue is removed. This will allow access to the implant and the cover screw, which must be replaced by a healing abutment. (D) A healing abutment of sufficient length and width is chosen to support the newly formed tissue.
Figure 3
Figure 3
Case report. Notes: (A) Initial presentation. Tooth 21 was fractured subgingivally, and tissue was inflamed and cyanotic. (B) Periapical radiography showing the remaining short root and level of interproximal bone. (C) Presentation at osseointegration check. Peri-implant tissue is healthy, but located at an apical level when compared to the adjacent tooth. (D) Periapical radiography of the implant replacing tooth 21. (E) Occlusal view of the healing abutment. (F) Tunnel preparation extending apically using curved elevator. (G) Connective-tissue graft harvested from the contralateral side of the palate. Wide, thick tissue is needed. (H, I) The CTG is inserted into the dome first buccally then palatally and stabilized by 6-0 sutures. At least two-thirds of the graft has to be covered to allow the survival of the uncovered part. (J) Healing of the area at 2 weeks. (K) Amount of vertical tissue augmentation achieved at the uncovering of the implant at 6 weeks. (L) Final cement-retained crown. Adequate esthetic results were achieved with harmonious gingival margin between the implant and the adjacent teeth. (M) Occlusal view showing amount of augmented tissue on the buccal aspect. Abbreviation: CTG, connective-tissue graft.
Figure 4
Figure 4
24-Month follow-up. Notes: (A) Stable esthetic results were achieved with the gingival margins on both central incisors at equal levels. (B) Buccal soft-tissue augmentation is maintained. (C) Patient smile. (D) Periapical radiography of the implant replacing tooth 21 with stable bone level.

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