Surgical & Soft Tissue Healing Protocol

When placing single dental implants, the use of a conventional surgical flap that includes the interdental papillae has been compared with a modified design that did not sever the two interdental papillae.4 The modified flap design preserved at least 1 millimeter of the papillae adjacent to the natural teeth. A reduction in crestal bone loss was noted and this enhanced bone preservation could improve the esthetic result achieved.

The longer the area has been edentulous, the more likely there will be a soft tissue discrepancy due to bone resorption and concomitant changes in the soft tissue contour. Therefore, it is generally felt that emphasis should be placed on retaining soft tissue form rather than restoring lost tissue. Methods of retaining soft tissue form and location include immediate implant placement and immediate placement of a provisional restoration when these procedures are indicated.

Immediate implant placement and provisionalization following extraction of a tooth has shown successful results in the maxillary esthetic zone and papillae have been preserved.5 It has been judged to be most predictable when the distance from the free gingival crest to the osseous crest is 3 millimeters on the facial surface of the tooth to be extracted and 4.5 millimeters on the interproximal surfaces of the adjacent teeth since greater measurements will likely produce deficits in the soft tissue esthetics.

A technique has been reported whereby the papilla can be retained between adjacent single implants.6 This inter-implant papilla preservation involves alternate immediate implant placement and provisionalization, one following the bone integration period of the other. The process involves extracting one of the two teeth, immediately placing the implant, and then attaching a provisional restoration with the desired profile as it emerges from the soft tissue. In this way, the soft tissue around the implant is preserved in its normal location. After six months, the procedure is repeated for the adjacent tooth, thereby preserving the inter-implant papilla.

It is important to make impressions for implants that record the existing position of the peri-implant mucosa so crowns and fixed partial dentures can be fabricated with forms that support or enhance the soft tissue form. It is also important to make the impressions after all healing has occurred so there will be no additional mucosal changes that negatively affect the esthetic result after a restoration has been fabricated or placed. The amount of soft tissue recession that occurs following abutment connection surgery has been measured in a one-year prospective study.7 The authors indicate about 1 millimeter of recession can generally be expected following abutment connection surgery. Since most of the recession occurred within the first three months, the authors proposed waiting three months after abutment connection surgery before making the definitive impression.