[Surgery]  Building Papillae on Implant Surgery Day

Hi Guys,


I'm placing implant #14 on Friday and want to try and build a papillae while in there along with an immediate temp.

Any tricks on papillae building?  I know that we talked about it at the tissue course but that seems like such a long time ago!  I'm pretty comfortable with the standard buccal recession CT grafts but this is new to me.

My concern is that if I place the implant with a standard flap design will the CT graft have enough of a blood supply to survive from the underlying bone?  The CT grafts I've placed have been placed in a recipient site that is partial thickness envelope style flap design not full thickness.

If I tried to place the implant flapless I could do the CT graft with the partial thickness flap but I may not get enough stability for immediate temporization and how would I cover the cover screw.

How should I go about this? Do you think I can get a reasonable looking papillae with the CT graft...enough to reduce the black triangle that will result after the crown?




by Cindy Sidhu at Tue, May 10, 2011 6:35 PM

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Bernard Jin Replied at Fri, May 13, 2011 3:35 AM

Hi Cindy, Much of papilla rebuilding depends on the existing state of the gingiva and level of adjacent bone of the site pre surgery. I am assuming you are interested in rebuilding the papilla between tooth 1.4 and 1.3. Assuming there is adequate crestal bone levels distal to the canine and adequate soft tissue thickness, sometimes you can perform tissue molding by using a screw retained temporary crown on the implant. Then, over time, you can gradually add flowable composite to the lateral emergence profile of the temp. crown over a period of several weeks. In essence, tissue moulding. If there is inadequate soft tissue, you should probably perform a CTG along with the implant placement. Then do the tissue moulding at a later date. Sometimes, you can perform a rotated pedicle in your implant flap design (in this case, the connected base is located at the mesio-buccal of the edentulous space). Then when you place the provisional implant supported crown, it supports, holds and 'compresses' the epithelium into the future papilla. This is more of an advanced technique - and its success is largely dependent on the flap design, maintenance of blood supply, provisional restoration emergence profile, etc. Again, I would definitely not promise the patient anything in terms of outcome. Best wishes, Bernard

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Mark Kwon Replied at Thu, May 12, 2011 8:12 PM

Hi, Cindy. Thank you for your posting. This is a tough case to rebuild papillae. (papillae rebuilding is never a predictable task). Especially if you are trying to build distal to this #13. Two factors of obstacles: 1) Triangular shape of canine makes the papillae reconsturction much more difficult due to amount of tissue you need to fill the 'black triangle' 2) remaining interproximal bone height distal to #13 may not be high enough to support the papillae you are about to rebuild. If you are attempting to do this, please let pt know that there is no guarantee that this will work. There's two ways to approach this: one is staged approach, Implant placement; bury the implant with cover screw; place CTG over the top via standard CTG approach(take from palate) or VIP flap design. Wait for few months and then mould the tissue using temporary screw retained crown. Second approach, is implant and immediate screw retained crown and simultaneous CTG by making hole punch through the CTG donor tissue (theres video casting on similar procedure that i posted on Video section on the map. Please view the video for additional information). Either way, the result will not depend much on your technique, but will mostly depend on what the remainig interproximal bone level is. Dont forget, the 4mm rule!! papillae will only grow back upto 4mm from the level of the interproximal bone!!! Good luck, - mark

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Cindy Sidhu Replied at Tue, May 10, 2011 7:19 PM

Here is the photo hopefully!