The International Journal of Periodontics & Restorative ... · periodontal disease around the remaining teeth 3. Systemic diseases or medication that could have altered the tissue

The International Journal of Periodontics & Restorative Dentistry

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Volume 38, Number 1, 2018

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©2018 by Quintessence Publishing Co Inc.

1 Clinical Professor and Director of Clinical Research, Ashman Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, New York, USA.

2 Implant Resident, Ashman Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, New York, USA.

3 Clinical Assistant Professor, Ashman Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, New York, USA.

4 Program Director, Ashman Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, New York, USA. Correspondence to: Dr Stuart J. Froum, 17 W 54th Street, Suite 1C/D, New York, NY 10019, USA. Fax: 212-246-7599. Email: [email protected]

Incision Design and Soft Tissue Management to Maintain or Establish an Interproximal Papilla Around Integrated Implants: A Case Series

Maintenance or reconstruction of interproximal papilla for a successful dental implant restoration can be challenging. To date, the results from various surgical and prosthetic techniques to maintain or regenerate papilla adjacent to dental implants have been unpredictable. To maintain the quality of the soft tissue around an implant, the blood supply must be preserved and formation of scar tissue must be minimized during surgery. Therefore, incision design is vital to producing an esthetic and successful dental implant restoration. In this study, specific incision designs and soft tissue management techniques were used to preserve or create interproximal papilla around single or adjacent implants. Int J Periodontics Restorative Dent 2018;38:61–69. doi: 10.11607/prd.2978

Dental implants have demonstrated high long-term survival rates when placed in healed alveolar ridges or with immediate placement follow-ing tooth extraction.1–3 Today, how-ever, the clinician’s goals extend beyond mere implant survival.4 The goal of both the clinician and the patient is implant success, which im-plies a functional and stable implant with stable bone levels and esthetic soft and hard tissue contours, in-cluding intact papilla adjacent to the implants.

One of the challenges in creat-ing an esthetic and successful im-plant restoration is maintenance or reconstruction of the interproximal papilla. Many surgical and pros-thetic techniques have been at-tempted to regenerate missing interproximal papilla adjacent to implants.5–8 The results to date have been unpredictable.9,10 The papilla height between an implant and a natural tooth was reported to average 4.5 mm, with a maximum of 5 mm 1 year after final prosthesis insertion.11 The average height of interproximal tissue between two adjacent implants from the crestal bone peak to the height of the pa-pilla has been reported to be ap-proximately 3.5 mm.12 However, improper management of soft tis-sues often results in loss of papilla between teeth and implants, which is difficult to correct.13

Stuart J. Froum, DDS1

Wendy Chia-Wei Wang, BDS, MSc2

Tarek Hafez, BDS2/Takanori Suzuki, DDS, PhD3

Yung Cheng Paul Yu, DDS3/Sang-Choon Cho, DDS4



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Three essential factors for maintaining or regenerating soft tissue quality and volume around implants are preservation of the blood supply to the adjacent papil-la, preservation of the bone on the adjacent teeth, and minimal scar tis-sue formation during surgery.14 The blood supply to the wound margin, which represents the main nutrition for tissue survival, is critical for opti-mal wound healing.15 When soft tis-sue becomes rigid and nonflexible as a result of traumatic manipulation or previous surgical interventions, it does not allow for adaptation or flexibility around implants. Tis-sue that remains resilient, flexible, and viable (referred to as moldable tissue) depends on careful han-dling and proper incision design.16 Knowledge of incision design is an essential factor in preserving blood supply, obtaining moldable tissue, and regaining or creating interprox-imal papilla.

The purpose of this study is to present a retrospective series of 14 consecutive cases of 22 implants (either single or two adjacent) in the esthetic zone, where specific incision designs and soft tissue management techniques were used at the time of implant placement and at the second-stage abutment or provi-sional restoration surgery. These fac-tors helped preserve and, in some cases, establish the interproximal papilla around the implants.

Materials and Methods

Clinical data in this study was ob-tained from the implant database

(ID). The data was extracted as deidentified information from the routine treatment of patients at the Ashman Department of Peri-odontology and Implant Dentistry at the New York University College of Dentistry, Kriser Dental Center. The Office of Quality Assurance at New York University College of Dentistry certified the ID. This study is in compliance with the Health Committee on Activities Involving Human Subjects.

Study Subjects

A total of 14 consecutive patients from the database were included in this study. Of these patients, 8 received 10 nonadjacent implants while 6 received 2 adjacent im-plants. The implants were placed using an early/delayed approach following socket healing as part of the replacement of extracted hopeless teeth. The patients in-cluded 6 males and 8 females. The treatment sites included central incisors, lateral incisors, and pre-molars.

Inclusion Criteria

Patients who had implants placed using a two-stage implant protocol with the following parameters were included:

1. Tooth or teeth in the esthetic zone that required extraction due to periodontal disease, root fracture, or failure of endodontic treatment and

were replaced with implants. Patients who had presurgical trauma to papilla from trauma due to extraction or from overcompression by provisional prosthesis were noted but not excluded.

2. Teeth adjacent to the proposed implant site were required to be periodontally healthy (no bleeding on probing) with ≤ 5 mm clinical attachment loss.

3. Patients who had taken a presurgical cone beam computed tomography (CBCT) scan prior to implant placement.

4. Type 2 or 3 extraction socket morphology (partial loss of buccal bone plate or soft tissue according to published extraction socket classification) present at time of implant placement.17

5. Implants that were placed 4 to 6 weeks following tooth extraction.

6. Implants that had papilla preservation incisions at placement and U-shaped incision designs (with divergent arms open toward the palatal) at second-stage surgery.

7. Implants with provisional abutments of a smaller diameter than the implant diameter (platform switching), which were connected at second-stage surgery.

8. Patients who returned to the Department of Periodontology and Implant Dentistry or to their own dentist for maintenance and monitoring at least 2 to 3 times per year.



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Exclusion Criteria

Patients were excluded if they met the following criteria:

1. Implant placement with one-stage protocol

2. Generalized chronic periodontal disease around the remaining teeth

3. Systemic diseases or medication that could have altered the tissue integration of dental implants (ie, uncontrolled diabetes, a history of radiation therapy, active autoimmune diseases, a recent history of intravenous bisphosphonates)

4. Parafunctional habits5. Inadequate home care

compliance6. Pregnant or lactating women or

women intending to become pregnant within 1 year of implant placement

Clinical Procedures

Presurgical CBCT scans with implant simulation (Simplant 17.0, Dentsply) were prepared. Any site with a buc-cal plate of bone of < 2 mm on the simulated implant was planned for simultaneous implant placement and horizontal ridge augmentation

using a xenograft and resorbable membrane barrier.

The incisions for implant place-ment for a single implant or two adjacent implants used a papilla preservation flap approach. Com-bined with periosteal releasing in-cisions, these preserved the soft tissue blood supply and allowed flap advancement where necessary following implant placement and horizontal ridge augmentation (Figs 1a to 1c, 2a, and 2b).

Horizontal ridge augmentation was performed simultaneously in 21 of the 22 implant placement proce-dures and included bone decorti-cation and the use of small particle

Fig 1 (a) Clinical view of a missing maxillary left lateral incisor. (b) Papilla preservation incision design for ridge augmentation. (c) Flap elevation allowed for access to the bone for implant placement. (d) Delivery of an implant-supported fixed prosthesis. (e) Radiograph of abutment insertion. (f) Final delivery of the implant-supported fixed prosthesis.

a

d

b

e

c

f



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anorganic bovine bone (BioOss 0.25–1.0 mm, Geistlich). The bone substitute graft was covered with a resorbable collagen membrane (Bio-Gide, Geistlich) stabilized by tacks into the bone or with resorbable su-tures through the periosteum.

Implants were placed using a surgical guide from an ideal wax-up, made of thermoplastic material, and following manufacturer instruc-

tions. All implants had cover screws placed and were submerged when horizontal augmentation proce-dures were used. Complete closure of the graft, membrane, and flap was achieved without tension using resorbable chromic 4-0 and 5-0 gut sutures (Ethicon) (Figs 2c and 2d).

At least 90 days after implant placement, second-stage abutment insertion surgery was performed

following administration of local an-esthesia. A U-shaped incision with divergent arms open toward the pal-atal was reflected (Fig 2e). The cover screw was exposed and removed. A platform-switching abutment was connected. On the same visit, the provisional prosthesis was fabricated and placed, leaving enough clear-ance in the embrasure area for the papilla to reform (Fig 2f). All patients

Figs 2a to 2f (a) Clinical view of missing maxillary central incisors. (b) Incision design used for tissue preservation. (c) Flap closure post–implant placement with horizontal ridge augmentation using a resorbable membrane barrier. (d) Clinical view at 2-week follow-up. (e) U-shaped incision design for second-stage surgery. (f) Opening of the cervical embrasure space.

a

d

b

e

c

f



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were given postoperative home care instructions, which included nondis-turbance of the papilla area.

Clinical photographs were taken at various visits following prosthetic loading with a fixed prosthesis to monitor the tissue response (Figs 2g and 2h).

Clinical and radiographic ex-aminations were performed by two independent calibrated clinicians to evaluate the presence of papilla at each postsurgical and maintenance visit (Figs 1d to 1f, 2i, and 2j). In cas-es of disagreement, a third calibrat-ed clinician made the final decision. The Jemt papillae index was used to evaluate the presence and height of the papillae. A Jemt score of 0, 1, or ≤ 2 was recorded as no papilla present, and a score of > 2 or 3 was recorded as papilla presence.18

Results

A total of 22 implants in 14 patients were followed up to 7.25 years (range: 6 to 7.25 years) with all im-plants surviving following loading. The presence of interproximal pa-pilla with a Jemt score of > 2 or 3 around the implants was observed in 12 of 14 patients (90.9%). The summary of the results is shown in Tables 1 and 2.

Discussion

The interproximal papilla is the gin-gival portion of the periodontium that occupies the space between two adjacent teeth.19 It acts as a bio-logic barrier in protecting the peri-odontal structures, but it also plays

a crucial esthetic role. Therefore, it is important to maintain the papillary integrity during implant surgery, es-pecially in the esthetic zone.20 Vari-ous surgical techniques have been proposed to preserve or regener-ate interproximal papilla around implants. The techniques described generally fall into two broad catego-ries: (1) specific incision and suture designs7,8,21,22; and (2) fillers or soft tissue grafting to fill the interproxi-mal spaces.23–26 However, consistent results have not been demonstrat-ed.27–29 Nonsurgical intervention such as orthodontic forced eruption has also been used to generate the papillae, but additional treatment time and costs are involved and the results are not predictable.30,31

The present case series dem-onstrated that the interproximal

Figs 2g to 2j (g) Clinical view at 4-month follow-up after second-stage surgery. (h) Clinical view at 4-year follow-up showing the papilla between the central incisors. (i) Clinical view and (j) radiograph of the implant-supported fixed prosthesis (a probe was attached to measure the bone level radiographically).

g h

i j



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papilla around a single or two ad-jacent implants can be predictably maintained or regenerated by using specific incision designs at the time of implant placement and second-stage surgery. Unlike techniques that required extensive soft tissue manipulation/mobilization/grafting to recreate the papilla, the incision designs proposed in this article are based on the principles of preserva-tion of vascular supply and preven-tion of scar tissue formation as the key elements in maintaining and/or obtaining papillary integrity. The result of this case series is consistent with other techniques where vascular

supply was minimally disrupted and papillary integrity was preserved.32,33

The vascularity of the papilla is supplied by the vascular anasto-moses crossing the alveolar ridge.34 Repeated disruption to the vascular supply can lead to scar tissue for-mation as a result of fibroblasts be-coming prematurely activated and forming excess fibrotic tissue.35 This tissue becomes dense, rigid, difficult to mold, and significantly less vascu-larized. Minimizing scar tissue for-mation enables the gingival tissue to be reshaped under light pressure and rebound to its original form on removal of pressure. This character-

istic allows molding of the gingival tissue with intermittent pressure to maintain or regenerate the integrity of the papilla.

The present case series intro-duced a sequence of procedures to maintain or reconstruct the inter-proximal papilla (Table 3). The pre-requisite to employ the procedures described is that teeth adjacent to the proposed implant must be periodontally healthy with ≤ 5 mm clinical attachment loss. The specific incision design used at the time of horizontal ridge augmentation and implant placement preserves the pa-pilla, retaining maximum vascularity

Table 1 Clinical Data for Adjacent Implants

PatientImplant

site (FDI)Prior trauma

to papillaHorizontal

augmentation Provisional placed at second stage

Papilla regeneration based on Jemt papilla score Follow-up

(y)Mesial Interproximal Distal

1 11, 21 No Yes Yes Yes Yes Yes 7.252 11, 21 Yes Yes Yes Yes No Yes 6.53 21, 22 No Yes Yes Yes Yes Yes 74 11, 21 No Yes Yes Yes Yes Yes 75 11, 21 No Yes Yes Yes Yes Yes 6.46 11, 21 No Yes Yes Yes Yes Yes 6.8

Table 2 Clinical Data for Single Implants

PatientImplant

site (FDI)Prior trauma

to papillaHorizontal

augmentation Provisional placed at second stage

Papilla regeneration based on Jemt papilla score Follow-up

(y)Mesial Interproximal Distal

7 12 No Yes Yes Yes N/A Yes 6.27 21 No Yes Yes Yes N/A Yes 6.28 14 No Yes Yes Yes N/A Yes 6.89 22 No Yes Yes Yes N/A Yes 6.89 11 Yes Yes Yes Yes N/A Yes 610 22 Yes Yes Yes Yes N/A No 6.211 21 No Yes Yes Yes N/A Yes 712 11 No Yes Yes Yes N/A Yes 6.713 21 No No Yes Yes N/A Yes 6.414 12 Yes Yes Yes Yes N/A Yes 7



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and minimizing scar tissue formation. A U-shaped inci-sion with its divergent arms opening palatally without sutures was employed at the second-stage implant un-covering (Fig 2e). The incision was designed to avoid an indentation formation following the incision line. If a U-shaped incision is made with its diverging arms open-ing labially, recession of the labial soft tissue, incision indentation, and scar tissue formation often result, com-promising the esthetic outcome as seen in Figs 3 and 4. The flap was minimally elevated following the incision, and the implant-supported provisional prosthesis, with

Fig 3 (a) U-shaped incision with diverging arms opening labially. (b) Soft tissue defect due to labial U-shaped incision design. (c) Scar tissue formation labially.

Fig 4 Example of scar tissue formation labially.

a b

c

Table 3 Sequential Procedures to Preserve Papilla

Sequence Surgical Trauma Restorative Avoid

Extraction No incision No Flipper/Fixed Incision

Ridge augmentation Papillary sparing Minimal Flipper/Fixed Midcrestal incision

Stage 1: Implant placement

Papillary sparing Minimal Flipper/Fixed Midcrestal incision

Stage 2: Implant uncovering

U-shaped incision with divergent arms open toward palatal

No Convert flipper to fixed/fixed

Labial incision

Stage 3: Prosthetic connection

None No Open embrasure space

Pressure on papillary tissue



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designed clearance, was placed to encourage soft tissue growth and help mold the soft tissue (Fig 2f). This sutureless technique with a minimally invasive incision preserves the blood flow to the papillary soft tissue and therefore minimizes scar tissue formation. In addition to im-proved esthetics, minimal postoper-ative discomfort was reported. The case demonstrated in Fig 2 was a heavy smoker. Despite the reduced healing potential and tissue vascu-larity typically associated with heavy smoking,35 the proposed techniques have re-established interproximal papilla between two adjacent im-plants. The interproximal bone peak associated with neighboring natural teeth maintained the distal papillae of implant restorations. Avoiding in-vasive surgery is considered one of the most predictable methods for soft tissue maintenance.14 The pro-posed sequence avoided incisions that repeatedly cross the papillae and create areas with compromised vascularization and lead to compro-mised wound healing and increased scar tissue formation.36

Careful planning and meticu-lous execution to maintain healthy soft tissue should be performed throughout all procedures, with the goal of obtaining resilient and less fibrotic soft tissue. These consider-ations include atraumatic tissue han-dling, avoidance of any large flap reflection, minimal tension during reapproximation and suturing, ad-equate tissue hydration, expedient surgical procedures, and provisional prostheses that do not compromise blood supply. Although the data in this study included a small number

of patients and implants, the results to date are comparable to those by Kan et al,37 who reported on a 2- to 8-year follow-up in a study on max-illary anterior single implants. Kan et al37 suggested that in the pres-ence of proper interproximal em-brasure form (papilla sparing) and underlying bony support, a certain degree of spontaneous papilla re-generation could occur over time. Although that study involved im-mediate placement of implants with provisionalization, the underlying concepts are similar to those used in the current study in which main-taining soft tissue quality during the course of implant surgery remained a critical factor in the papillary main-tenance and growth observed.

Conclusions

To achieve and maintain the papil-lary tissue integrity around single or adjacent implants, careful planning and meticulous execution of each procedure is necessary. This pilot study demonstrates specific incision designs and soft tissue manage-ment techniques used at different stages to achieve maintenance and regrowth of the interproximal papilla around single or adjacent implants. The critical factors for success were the preservation of the blood sup-ply to the adjacent papilla, preser-vation of bone on the teeth adjacent to the implant, and minimal scar tis-sue formation. However, long-term follow-up of prospective studies with an increased number of cases are needed to further validate the results achieved in this case series.

Acknowledgments

The authors reported no conflicts of interest related to this study.

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Documents

The International Journal of Periodontics & Restorative ... · periodontal disease around the remaining teeth 3. Systemic diseases or medication that could have altered the tissue