Soft tissues can be influenced during many stages
of implant treatment. The second-stage surgery is an example where the labial
mucosa exists in a collapsed state.(1) It would require the support
of the prosthetic components in order to develop natural-looking
peri-implant soft tissue contours. Mucogingival surgical corrections can also be
used after implant placement to reconstruct the missing aesthetic
biological contours surrounding the already existing implant-supported
The greatest challenge in creating esthetically
successful implant supported anterior restorations is the reconstruction of the
interproximal papilla. Many trials have been attempted to reconstruct the
papilla by either soft or hard tissue techniques. The soft tissue management
techniques consist of free gingival grafts,(5) coronally positioned flaps,(6)
different types of pedicle grafts,(7) free connective tissue grafts with pedicle
grafts,(8) guided tissue regeneration procedures,(9) and guided tissue
Misch et al(11) has introduced the split finger
technique to bulk the soft tissue around a peri-implant papilla, which showed
predictability and clinical efficiency. A sulcular incision is made 2 to 3 mm to
the palatal side from each tooth with a loop design (at least 2.0-2.5 mm)
adjacent to the implant location. The incisions are then joined facially with a
semicircular incision at the preplanned free tissue margin of the implant crown.
The facial "fingers" are elevated to the desired inter-implant height for the
papillae. The middle "palatal finger" is then split and reflected to the
respective mesial and distal sides (each is at least 2.0-2.5 mm wide). The soft
tissue maintains its elevated position on the healing abutment. The split-finger
papillae approach can also be used for two or more adjacent implants. A modified
vertical mattress suture is then used to suture each papilla using 4-0 or 5-0
sutures. One interrupted suture at the base of the papilla is suggested when the
inter-proximal tissue is thin. The authors have evaluated twenty-one patients
with 39 implants consecutively placed in the maxillary anterior region six
months to one year after prosthodontic restoration. Results showed the efficacy
of the technique in providing an alternate procedure to promote/augment papillae
formation around dental implants.
Adriaenssens(12) described a similar approach to
enhance the papilla formation around dental implants in the second stage surgery
either in single or multiple teeth situations. The Palatal Sliding Strip Flap
design helps forming the papillae between implants and between natural teeth in
the anterior area of the maxilla. The flap is designed and managed so that the
palatal attached mucosa slides in a labial direction to create papillae and at
the same time augment the labial ridge. The procedure entails an incision that
allows the dissection of the masticatory mucosa from the underlying bone in
full-thickness using a sulcular approach in a labiopalatal direction
perpendicular to the ridge crest, both on the mesial and distal aspects of the
implant. A full thickness horizontal incision is extended from the distal to the
mesial on the palatal side comprising approximately two-thirds of the distance
between the two teeth. Two incisions, parallel to each other, are then made in a
labiopalatal direction to create a partial thickness flap extending in the
palate, leaving the periosteum intact. This extension portion is designed into a
strip to be located at the mesial aspect of the implant. A partial-thickness
horizontal dissection is made to connect the two parallel incisions to form the
sliding palatal strip. A final incision dissects the masticatory mucosa from the
bone and incorporates the partial-thickness incision into a full-thickness
incision in a labial direction. Once the incisions are made, the partial- and
full-thickness flaps are prepared for flap elevation. The partial-full-thickness
flap with a strip is raised to uncover the implant. The healing abutment is
connected and a semilunar incision is made to the distal, away from the side of
the strip. Care must be taken that the semilunar incision is coronal to the
cemento-enamel junction or the gingival line of the adjacent teeth; otherwise,
the healing abutment will displace the flap apically and the final gingival
margin will heal apical to the gingival line of the adjacent teeth. The
semilunar incision will provide a second strip, which gives two pedicles. The
distal pedicle created by the semilunar bevel incision will be rotated 90
degrees in the palatal direction around the healing abutment. The mesial pedicle
with the partial thickness component from the palate will fill the
inter-proximal space. This flap manipulation between the teeth and the healing
abutment will allow the reconstruction of two papillae in one time. The buccal
soft tissue augmentation is related to the support by the healing abutment and
the buccal repositioning of the flap. Simple sutures are used around each
newly-formed papilla to maintain the flap in position.
In case of two adjacent implants, the flap design
for multiple restorations in the anterior maxilla follows the general principle
of a palatal strip of split-thickness tail harvested from the palate, combined
with a full-thickness flap displaced in the mid-palate toward the sulcus of
adjacent tooth. The difference resides in the location of the palatal strip and
the semilunar incisions. The palatal strip of split-thickness connective tissue
tail harvested from the palate must be made between the implants. A
full-thickness incision in the mid-palatal area dissects the masticatory mucosa
toward each adjacent tooth. A final incision dissects the masticatory mucosa
from the bone over the ridge crest, creating a full-thickness sulcular incision.
Once the incisions are made, the partial-and full-thickness flaps are prepared
for elevation. The partial-full-thickness flap with a strip adjacent to the
distal tooth is raised to uncover the implants and their cover screws. The
healing abutments are connected, allowing the flap to be sustained on the buccal
side. Two semilunar incisions are made toward the contra-lateral side of the
strip. Care must be taken that the semi-lunar incision is coronal to the
cemento-enamel junction; otherwise the healing abutment will displace the flap
apically. The two semilunar incisions will provide two small pedicles. They are
rotated in the palatal direction, each one creating a tissue augmentation in the
interproximal space between the tooth and the implant. The palatal strip of
partial thickness will be foiled to fill the inter-proximal space between the
two implants. The soft tissues are repositioned and sutured within the pedicles
using simple sutures.
(Figure 3A) A
mucoperiosteal flap is being used to expose the implant.
(Figure 3B) The mid buccal incision is used and the flap
(Figure 3C) The post operative result and post restorative
showing an excellent tissue scar free condition.
The red arrows pointing at the tissue scar and tag
formation due to the improper tissue edges adaptation.
The gap formation between the flap and the wound edges due
to the rigidity poor flexibility of the keratinized tissues.
An illustration showing the incision design of the
mid-buccal release of flap.
As keratinized mucosa lacks elasticity, the
adaptation of the mucoperiosteal flap to the sides of to the wound edges can be
a difficult task. When the tissues are moved from the palatal to the buccal side
to allow for tissue bulking, it should be adapted to the wound edges and sutured
to the adjacent papillae bilaterally, which sometimes becomes a difficult task
to achieve. In order to allow for a bilateral tension free suturing to the
adjacent inter-proximal papillae, a mid-buccal vertical incision might be made
in the mucoperiosteal flap of the second stage surgery, to facilitate suturing
to the adjacent papillae. The incision should be as small as possible, i.e. does
not exceed 1 mm, restricted to the keratinized band, and does not involve any
vestibular tissues (Figure 1). The releasing incision allows flexibility of the
flap and eliminates the dead space or tissue ledges between the edges of the
flap and the adjacent papillary tissues (figure 2). The method has shown highly
predictable success rates in stabilizing tissue contours and achieving
harmonious margins (Figure 3).
The time allowed for soft tissue
healing after cosmetic reconstruction is important. Lazara(13) recommends
that consideration should be given to the healing period after any soft tissue
manipulation, as oral soft tissues require an ample time to heal and mend. A
stable soft tissue clinical condition must be attained before beginning or
continuing with other clinical procedures. This is also reaffirmed by Small and
Tarnow(14) who recommend a three-month waiting period for the soft tissue to
stabilize before selecting the final abutment or making the final impression
after the second-stage surgery.
1) S. R. Potashnick, Soft tissue modeling for the
esthetic single-tooth implant restoration, J Esthet Dent 10(1998):
2) H. Israelsson and J. M. Plemons, Dental
implants, regenerative techniques, and periodontal plastic surgery to restore
maxillary anterior esthetics, Int J Oral Maxillofac Implants 8(1993):
3) B. Liljenberg, F. Gualini, T. Berglundh, et
al., Some characteristics of the ridge mucosa before and after implant
installation: A prospective study in humans, J Clin Periodontol 23(1996):
4) P. K. Moy, M. Weinlaender, and E. B. Kenney,
Soft tissue modifications of surgical techniques for placement and uncovering of
osseointegrated implants. Dent Clin North Am 33(1989): 665–681.
5) Miller PD. Jr. Root coverage using a free soft
tissue autograft following citric acid application. Part 1. Technique. Int J
Periodontics Restorative Dent 1982; 2:65-70.
6) Harvey PM. Management of advanced
periodontitis: Part a. preliminary report of method of surgical reconstruction.
N Z Dent J. 1965;61:180-187.
7) Grupe E, Warren RF Jr. Repair of gingival
defects by a sliding flap operation. J Periodontol. 1956;27:92-95.
8) Nelson SW. The subpedicle copnnective tissue
graft: A bilaminar reconstructive procedure for the coverage of denuded root
sufaces. J Periodontol. 1987;58:95-102.
9) Tinti C, Vincenzi G, Cortellini P, et al.
guided tissue regeneration in the treatment of human facial recession: A 12-case
report. J Periodontol. 1992; 65:554-560.
10) Salama H, Salama M, Gaber D, et al.
Developing optimal peri-implant papillae within the esthetic zone: Guided soft
tissue augmentation. J Esthet Dent. 1995;7:125-129.
11) Misch CE, Al shammari.K, Wang. HL .Creation
of Inter-implant Papillae through a Split-Finger Technique. Implant Dent 2004;
12) Adriaenssens P, Hermans M,Ingber A, et al .
Palatal Sliding Strip Flap: Soft Tissue Management to Restore Maxillary Anterior
Esthetics at Stage 2 Surgery: A Clinical Report. Int J Oral Maxillofac Implants
13) R. J. Lazara, Managing the soft tissue
margin: The key to implant aesthetics, Pract Periodont Aesthet Dent 5(1993):
14) P. N. Small and D. P. Tarnow, Gingival
recession around implants: A 1-year longitudinal prospective study, Int J Oral
Maxillofac Implants 15(2000): 527–532.
By: Dr. Abd El
Salam El Askary
Soft Tissue Management for
The clinical outcome of the second stage surgery
predicts the aesthetic outcome of implant supported restorations to a great
extent. Numerous clinical trials have been recorded to increase the
predictability of the second stage surgery that includes versatile incision
designs. However, dead space, lack of tissue adaptation usually results in scar
tissue formation after the second stage surgery and subsequent poor aesthetic
results. This clinical report introduces an incision design that helps more
tissue adaptation and reduces dead space formation, the primary clinical results
Mailing address: 39 Abd El Salam Aref,
El Bostan, Alexandria, Egypt.
Tel: +20 3 586 6558
Mobile: +20 12 214 8642
Dr. Abd El Salam Elaskary.
Former associate clinical professor at
University of Florida
A visiting lecturer at University of New