Chapter 8
Papillary Construction After Dental Implant Therapy
The presence of a “black triangle” due to the absence of inter-proximal papilla between two adjacent implants has become a steady concern among implant surgeons and restorative dentists. Three main surgical methods have been proposed in the past at second-stage surgery (uncovering) to correct the problem. Palacci in 1995 suggested that a full-thickness flap be raised from the palatal side of the implant and a portion of it be rotated 90 degrees to accommodate the interproximal space of the implant. Possible compromise of the blood supply of the rotated small flap, limited amount of pedunculated soft tissue for some larger interproximal areas, and lack of keratinized tissue in cases with a narrow band of attached gingiva on the facial seem to be some of the limitations of this technique. In 1999, Adriaenssens et al. introduced a novel flap design, the “palatal sliding strip flap,” to help form papillae between implants and between natural teeth on the anterior area of the maxilla. The flap was designed and managed in a way that allowed the palatal mucosa to slide in a labial direction after dissection of two mesial and distal strips (to create papillae and at the same time augment the labial ridge).
Nemcovsky et al. in 2000 introduced a U-shaped flap raised toward the buccal; the nature of this design was essentially the same as the one introduced earlier by Adriaenssens, with some minor differences. In 2004, Misch et al. modified Nemcovsky et al.’s technique further by raising the U-shaped flap toward the palatal rather than the buccal side. In 2004, Shahidi developed a surgical procedure with the goal of guiding the soft tissue that formerly covered the implant over to the sides of the implant and to gently squeeze this piece of tissue after insertion of the healing abutment. This was done to provide enough soft tissue in the interproximal spaces to allow for papilla generation.
In brief, there is not one single technique that is universally accepted to be the one that works 100% of the time. Tissue engineering, with the implantation of fibroblasts in the papillary area, may, in the future, help solve this problem by providing more predictability.
- At second-stage dental implant uncovering, between an implant and a tooth or between two or more implants, to minimize the formation of a “black triangle”
- Thick periodontal biotype
- Thin periodontal biotype
- Lack of keratinized gingiva around the implant(s)
- Need to correct underlying bone
- A basic surgical set as described in Practical Periodontal Plastic Surgery
- Implant kit
- Healing abutments
In the single implant model, a small U-shaped flap is created to allow mobilization of the tissue in the mesial direction. Another U-shaped flap, mirror image of the first one and sharing the same buccolingual incision, allows mobilization of the tissues to the distal direction. Occlusally, these full- or partial-thickness U-shaped flaps form an H-shape design (Fig. 8.1). The exact location of the implant is obtained using periapical/ bitewing radiographs in combination with alveolar ridge mapping with an explorer following local anesthesia.
Fig. 8.1. Diagram showing the uncovering incision and procedures for a single implant occlusally (a) and buccally (b) and with the healing abutment in place (c).
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