|Year : 2014 | Volume
| Issue : 2 | Page : 170-175
Optimising esthetics in second stage dental implant surgery: Periodontist's ingenuity
A Suchetha, Prajakta Vasant Phadke, N Sapna, HR Rajeshwari
Department of Periodontics, DAPM RV Dental College, Bengaluru, Karnataka, India
|Date of Web Publication||16-Sep-2014|
Prajakta Vasant Phadke
Department of Periodontics, DAPM RV Dental College, CA-37, 24th Main, 1st Phase, J. P. Nagar, Bengaluru - 560 078, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Morphology of the peri-implant soft tissue adjoining the implant components plays a pivotal role in displaying the implant esthetics. Creating an implant restoration that cannot be distinguished from the rest of the natural dentition is the ultimate goal. Second stage surgery is often overlooked and is considered non essential phase but actually could determine the health of the peri-implant tissue .This phase gives an excellent opportunity to preserve, reconstruct and even maneuver the soft tissue to optimize the soft tissue profile around the implant components. The article aims at enumerating the various modalities available to contour the soft tissue profile around implants and thus help the practioners in optimizing esthetics during second stage surgery.
Keywords: Dental implants, esthetics, second stage surgery, soft tissue
|How to cite this article:|
Suchetha A, Phadke PV, Sapna N, Rajeshwari H R. Optimising esthetics in second stage dental implant surgery: Periodontist's ingenuity. J Dent Implant 2014;4:170-5
|How to cite this URL:|
Suchetha A, Phadke PV, Sapna N, Rajeshwari H R. Optimising esthetics in second stage dental implant surgery: Periodontist's ingenuity. J Dent Implant [serial online] 2014 [cited 2019 Aug 18];4:170-5. Available from: http://www.jdionline.org/text.asp?2014/4/2/170/140898
| Introduction|| |
Every implant exposure is unique, crucial and technique sensitive. The goal of the second stage surgery in esthetic zone is not only to expose the implant interface for performing the required restorative procedures, but also to create a healthy marginal attached mucosa around dental implants. 
The ability to preserve the architecture, modify and even improvise the soft tissue contour lie in the hands of the periodontist and this can greatly influence the overall restorative result. Four potential time points can be differentiated for soft/hard tissue management at the time of implant placement, during healing of the implant, during second stage surgery, and finally at the maintenance phase. 
The aim of this article is to compile the various techniques available to enhance esthetics in implant second stage in common to highly complicated clinical scenarios.
The treatment goals of second stage surgery in esthetic zone  would include preservation of the continuity of the keratinised tissue band, avoiding creation of the tissue margins that are defective, creating an implant-supported restoration that have symmetric contours, postoperative stable soft tissue conditions.
Ultimately establish and accomplish natural soft tissue dimensional architecture without formation of any scar tissue on labial gingival interface and most importantly preserve the inter-proximal papillae.
Implant exposure techniques were classified by Bichacho and Landsberg  in 1997 as additive which was performed to enhance tissue thickness when soft tissue thickness was deficient; Subtractive in which kertainised tissue overlying the coverscrew was excised and performed when optimal soft tissue volume was present and combination of both additive and subtractive techniques.
Another classification classified second stage surgery as excisional "Destructive" techniques using scalpel, tissue punch or laser and incisional "Regenerative" techniques that was further subdivided into without tissue transference and with tissue transference.
The decisive parameters that ultimately play a pivotal role include the characteristics of the tissues that overlie the implant (keratinised/nonkeratinised), the amount of attached gingiva, the thickness or the biotype of overlying mucosa and presence or absence of the interdental papilla. A very simple equation was developed by Hertel et al.  to help the clinicians is based on the amount of fixed mucosa is described in [Table 1].
The factors that would prove critical in predicting the final outcome would include blood supply for the viability and undisturbed wound healing,  optimal implant positioning especially the axial orientation that would influence the distance from the contact point to the osseous crest,  tissue biotype which influences the postoperative response to trauma,  platform switching favors biologic width development and minimizes the postoperative resorption,  and most importantly optimal distance between the implants and implant and natural teeth.
On regular basis the classic protocol  is carried out for the implant exposure which starts with a long incision over the crest and midway between buccolingual aspect through the gingiva from the site of the distal implant in mesial direction. Following a full or partial thickness flap is raised to establish access to cover screw. Osseous recontouring can be made and healing abutments will be placed. But the technique included some disadvantages like it caused more tissue manipulation leading to trauma involved and exposure of large area of the bone.
Enumeration of various modalities are done under the following as excisional techniques and incisional techniques as shown in [Table 2].
| Excisional techniques|| |
These techniques are ideal only if sufficient attached gingival tissue is present around the head of the implant; as this involves the removal and discarding of keratinised tissue covering the cover screw. These include using scalpel, soft tissue punching and laser using scalpel the following techniques are described Bernhart et al. described a minimally invasive procedure  consisting of vertical incision on the gingival crest covering the cover screw followed by a round incision about 1-3 mm around the tissue to be removed and with a blunt instrument stretching the tissue to remove the cover screw and placement of healing abutment.
Key hole access expansion for flapless implant second stage surgery  Happe et al. This procedure consists of excising approximately 1 mm 2 of soft tissue overlying the cover screw following this the hole would be firmly and slowly stretched using a microraspatory. Five minutes later the hole would be large enough for retrieval of cover screw and a larger healing abutment is placed. This would cause ischemia but the ultimate goal of expansion would have occurred. This procedure offers the following advantage such as minimal soft tissue trauma, minimal bone exposure, high ease of performance.
Soft tissue punching consists of excising a circular keratinised mucosa on top of cover screw using scalpel, gum punching tool or diamond bur. Though this technique gives the clinician the surgical ease it should be noted that this technique is sensitive as imperfect tissue punching could jeopardize labial tissue contour and cause unnecessary loss of keratinised mucosa. It is more of a guess work unless original surgical template is present to locate the exact location of cover screw and bone contouring is not possible in this technique.
Laser allows precise tissue trimming in a bloodless field and also allows control of depth of tissue removal.
| Incisional techniques without tissue tranfer|| |
Cosmetic incisions using microsurgial blades and avoiding perpendicular incisions to the bone preferably using blades at 45° angulations would allow more tissue adaptation thereby reducing tissue tag and scar formation.
A very simple technique consisting of "+" and "X" incision technique  would be sufficient and when adequate attached gingiva is present. This technique would first involve a small crestal incision that will later give place to a cross type [+] incision. Diagonal incisions are used [X] when the location of implant is exactly known.
| Incisional technique with tissue transferance|| |
Rotated palatal strap  was introduced by Nemcovsky and Moses. A predictable technique that technique consistently provides a wider zone of keratinized gingiva in the buccal aspect of the future maxillary implant-supported restoration.
This technique consists of crestal incision that would be given palatal to the implants with buccal releasing incisions and completed with the full-thickness flap delineation leaving proximal interdental papillae untouched [Figure 1]a. All tissues buccal to the crestal incision would be labially repositioned and implant cover screws would later be removed and replaced by healing abutments [Figure 1]b. A sharp, deep, internally Beveled incision More Details delineating a pediculated full-thickness palatal flap would be made and the rotated palatal flap [Figure 1]c would closely be adapted to healing abutments.
This procedure procures adequate zone of keratinized tissue around implants with added advantage of avoiding a large zone of exposed implant-supporting bone.
|Figure 1: (a) Crestal incision that would be given palatal to the implants with buccal releasing incisions and completed with the full-thickness flap delineation leaving proximal interdental papillae untouched. (b) All tissues buccal to the crestal incision would be labially repositioned and Implant cover screws would later be removed and replaced by healing abutments. (c) A sharp, deep, internally beveled incision delineating a pediculated full-thickness palatal flap would be made and the Rotated palatal flap|
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Nemcovsky et al. introduced a technique for implant exposure with simultaneous inter-proximal papilla reconstruction for maxillary implants  which consists of U-shaped incisions open toward buccal aspect with slight divergent arms [Figure 2]a. Adjacent papilla would remain adherent. Both sides of the incisions would be palatally connected. Outer edges of the incision and the papilla would be de-epithelised. A full thickness flap would be raised and healing cap would be placed. The flap would be split at the centre into mesial and distal halves [Figure 2]b. Each part of the buccal flap would be positioned over the de-epithelised papilla and would be secured with vertical mattress sutures.
|Figure 2: (a) U shaped incisions open toward buccal aspect with slight divergent arms. (b) The flap would be split at the centre into mesial and distal halves|
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Palatal sliding strip flap  was developed to help form papillae between implants and between natural teeth in the anterior area of the maxilla and at the same time augment the labial ridge by Adriaenssens et al.
This technique consisted of full-thickness sulcular and palatal displaced incision. At two-thirds of the distance between the two teeth, a full-thickness horizontal incision would be prolonged on the palatal side. Two incisions, parallel to each other in a buccopalatal direction, would be made to create a partial-thickness flap extending in the palate, leaving the periosteum intact [Figure 3]a Healing abutments would be later inserted and a semilunar incision would be made in the direction of the contralateral side of the strip [Figure 3]b. The pedicles would be disengaged and rotated toward the palatal direction to fill the inter-proximal space [Figure 3]c.
|Figure 3: (a) At two-thirds of the distance between the two teeth, a full-thickness horizontal incision would be prolonged on the palatal side. Two incisions, parallel to each other in a buccopalatal direction, would be made to create a partial-thickness flap extending in the palate, leaving the periosteum intact. (b) Healing abutments would be later inserted and a semilunar incision would be made in the direction of the contralateral side of the strip. (c) The pedicles would be disengaged and rotated toward the palatal direction to fill the inter-proximal space|
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The flap design for second-stage surgery appears to have several advantages like minimal surgical trauma; flap nutrition preservation; soft tissue augmentation; formation of papilla like tissue; and avoidance of a donor site with a second surgical area or multiple surgeries.
Pouch roll technique  a modification of roll flap technique was described by Park and Wang et al. This technique is simple, versatile for mild to moderate ridge deficiency by thickening the soft tissue around implant. In this buccal mini-pedicle flap 1-mm wider than the diameter of the implant platform would be raised and then de-epithelised [Figure 4]a followed by rolling of this mini-pedicle underneath the buccal pouch [Figure 4]b.
Misch et al. split finger technique  would comprise of a sulcular incision made 2-3 mm to the palatal side from each tooth with a loop design at least 2-2.5 mm adjacent to the implant location. The incisions would be joined facially by a semicircular incisions at the preplanned tissue margin of implant crown [Figure 5]a. Following this the facial fingers would be elevated to the desired inter-implant height for papillae and the middle "palatal finger" would then be split and reflected to respective mesial and distal sides [Figure 5]b and later would be secured by vertical mattress sutures.
Palacci and Nowzari technique to restore papilla like tissue around implants  would comprise of full thickness flap that would be elevated and reflected labially [Figure 6]a. Healing abutments would emerge from the tissues and hold them in place. Semilunar bevel incision would be made, recreating a scalloped shape similar to that of tissues around natural teeth [Figure 6]b. Later the pedicles would be rotated to fill the inter abutment and abutment-tooth spaces [Figure 6]c.
|Figure 4: (a) Buccal mini-pedicle flap 1mm wider than the diameter of the implant platform would be raised and then de-epithelised. (b) Rolling of this mini pedicle underneath the buccal pouch|
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|Figure 5: (a) A loop design at least 2-2.5 mm adjacent to the implant location. The incisions would be joined facially by a semicircular incisions at the preplanned tissue margin of implant crown. (b) the facial fingers would be elevated to the desired inter-implant height for papillae and the middle "palatal finger" would then be split and reflected to respective mesial and distal sides|
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|Figure 6: (a) Full thickness flap that elevated and reflected labially. (b) Semilunar bevel incision would be made, recreating a scalloped shape similar to that of tissues around natural teeth. (c) The pedicles would be rotated to fill the inter abutment and abutment-tooth spaces|
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Ramp mattress sutures  Tinti and Benfenati came up with an innovative technique of obtaining inter implant papilla with suturing technique. In this technique a sharp linear incision in a distomesial direction would be performed with a full thickness approach slightly palatal to the implants, starting 5 mm posterior to the most distal implant and finishing 5 mm mesial to the most mesial implant.
Long healing abutments would be placed and healing abutments would be able to keep the full-thickness buccal flap raised during the healing period. The vestibular gingival margin is in a more coronal position compared to the palatal gingival margin. Ramp mattress sutures would be placed to stabilize the flap at the new desired position.
"I" shaped incision for papilla reconstruction  Lee et al.
Labial horizontal incision would be given about 0.5-1 mm inside from the border of implant followed by vertical incision at the middle of the implant then a palatal horizontal incision would be given along the border of implant [Figure 7]. The flap would be reflected with care and the implant would be exposed to remove the cover screw. The healing abutment is later connected and both flaps would be folded up alongside the healing abutment intending them to heal without suture.
|Figure 7: Labial horizontal incision would be given about 0.5-1 mm inside from the border of implant followed by vertical incision at the middle of the implant then a palatal horizontal incision would be given along the border of implant|
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"M" shaped flap design was proposed for promoting implant esthetics  by Paolantoni et al. This design was proposed with an intension of preventing buccal marginal recession and to achieve an esthetic peri-implant soft tissue remodeling and predictable implant-supported gingivo prosthetic integration, particularly during the single tooth rehabilitations.
This technique consisted of an intrasulcular inner beveled incision which would be performed around the distal aspect of the adjacent teeth, rounding buccally and palatally and connecting with a M-shaped incision. The full thickness "M" flap would be raised to visualize the bone surface and connect the implant abutment. The flap would then be closed and sutured with a mattress monofilament suture at the gingival papilla to stabilize the flap around the healing cap [Figure 8].
|Figure 8: The full thickness "M" flap would be raised to visualize the bone surface and connect the implant abutment|
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Guided soft tissue augmentation (GSTA) with submerged healing abutments  was proposed by Salama et al. to overcome the dilemma of black triangles with three-dimensional enhancement of peri-implant soft tissue by tenting the repositioned flap over anatomical healing abutments of appropriate health.
In this procedure a full thickness labial flap would be coronally advanced to cover the healing abutment capable of supporting the vertical needs and allow the three-dimensional GSTA.
Tenting of soft tissue with appropriate healing abutments would allow space maintenance beneath the gingiva and organize the blood clot which would be replaced by soft tissue.
Six to eight weeks later healing abutments would be removed and replaced by temporary restorations.
Revised technique for stage-two surgery in the severely resorbed mandible  was proposed by Arnoux et al. that would limit the detachment of the lingual flap, augment the band of attached masticatory mucosa with a free gingival graft, deepen the vestibule, and prevent the reattachment of the muscles.
In this technique the incision would be made at the mucogingival junction, so that the entire band of keratinized masticatory mucosa would be included in the lingual flap.
It is very important that the lingual flap not be elevated in its entire length, but only around each implant so as to maintain maximum attachment to the body of the mandible.
A partial-thickness dissection through the muscles of the chin area would be performed on the labial vestibular aspect to obtain a free graft. Periosteal incision would be given at the base of the bed and the periosteum would be elevated and a band of exposed bone would be denuded to further minimize the reattachment of the muscles to the future peri-implant area.
Placement of healing abutments that are 5-6 mm above the gingival level would stabilization of the graft. The graft would be stabilized by means of interrupted and horizontal mattress.
| Conclusion|| |
There are various innovative methods for promoting and preserving the soft tissue profile around the implants. Second stage surgery should be given emphasis and not just thought as a process of uncovering the coverscrew. A whole lot can be done and is an excellent opportunity to give finesse to the soft tissue profiling around implant components. The biological, functional, esthetic needs of the individual patient can be sculpted with this essential step.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]